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Sensible Nutrition And body image Choices

SNAC Peer Educator Application

Please type or print in black ink

Name ________________________________ E-mail _____________________

College Address ___________________________________________________


Phone number ___________________________________________________

Permanent Address _______________________________________________


Phone number ___________________________________________________

College Major ____________________________ Current GPA ____________

Expected Date of Graduation ______________________________________

Pertinent Employment and Skills

Name of EmployerPositionDates of EmploymentIdentify any Transferable Skills

Student Organization Involvement

Indicate any student organizations you are in currently or will be involved in during the upcoming semesters.

OrganizationOffice Held (if any)Dates in Group

Statement of Interest

Please respond to the following questions on a separate sheet of paper.

1. Why are you interested in becoming a member of S.N.A.C.?

2. What quality/skills will you bring to the group? What skills would you like to develop while in the group?

3. Have you or someone close to you been affected with any type of eating concern? If so, how will this affect you in your work as a peer educator?

4. List any time constraints that will affect your involvement in S.N.A.C. (school, job, volunteer activities, etc.)

5. Describe your level of interest, experience, and skills in each of these categories: promoting campus events, giving a presentation, designing an awareness event/project.

6. Please include any additional information about yourself that you feel is relevant to joining S.N.A.C.


Each candidate must have at least one reference (preferably from an employer, academic advisor, or other adult who can give an objective overview). It is the applicant’s responsibility to ensure that the recommendation form is completed and returned to Room 268, Lafene Health Center.

Reference name, address, and telephone number:

Reference name, address, and telephone number:

Please Note:
This completed reference form should be returned by October 1st

 (If you have any questions, call 785.532.6595 or send an email to

I hereby certify that all statements and answers set forth on this application are complete and true.  I understand that false statements or omissions will cause the termination of my application.

Signature of Applicant _________________________________________________

Date _________________________________

By placing my initials here (__________), I DO NOT consent to have my photo used in marketing, educational and promotional material, to include web site, display and printed brochures, produced for Lafene Health Center.


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