Student Information Page

Дата канвертавання25.04.2016
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Page 1
Student Information Page
NAME ________________________________________________________

SEX (circle one) Male Female SCHOOL I.D. #_____________________

BIRTHDATE (mm/dd/yy) __________ HOME PHONE #_______________

HOME ADDRESS________________________CITY___________ZIP________

E-MAIL ADDRESS________________________________________________

If you are selected to be in the PAL class, which elective class would you like to have dropped from your schedule? _______________________________________________

Read the following statements and initial in the blank provided that you understand each one:

  1. I understand that if I am a PAL I will have to, and will be willing to, give up some of my personal time after school and on the weekends. ________

  2. I understand that if I am a PAL I will have to, and will be willing to, volunteer during my lunch period when needed. _______

  3. I understand that if I am a PAL I will have to, and will be willing to, work with special needs students. __________

  4. I understand that if I am a PAL I will occasionally have to , and will be willing to, be taken out of school to participate in PAL-related activities (i.e. attending a ROPES course activity, giving presentations to elementary and/or middle school

students, etc.) __________

  1. I understand that if I am a PAL I will be looked upon as a role model by my peers, by my community, and by youth, and I will pledge as such. _________

Attach a current picture at the top of this page with a staple or paper clip.

Page 2

Please answer the following questions on a SEPARATE sheet of paper using complete sentences. Limit your answers to two sheets of paper (front only). It is preferred that you type your answers. DO NOT put your name on your answer sheet.

  1. Why do you want to be a PAL?

  1. What are some of your interests and activities outside of school?

  1. What school activities, clubs, sports, etc., are you involved in and what leadership roles do you hold or have held recently?

  1. What characteristics do you think a person should have to be a peer helper? Explain how you would use these characteristics to be an effective peer helper.

  1. Describe your personality.

  1. What do you think are your biggest strengths? What are you biggest weaknesses?

  1. Describe a difficult time in your life. How did you handle it? How might this make you more effective as a PAL?

  1. What makes you “stand out” above the other applicants?

Return COMPLETED PAL application

To: _______________________
Return date: ________________

Page 3

* PAL applicants must make copies of this recommendation page for each of their classroom teachers.

PAL Teacher Recommendation

PAL Applicant: ______________________________

Teacher Name: ______________________________ Period: ________


PALs (Peer Assistance and Leadership) is an advanced class that trains students to work as peer helpers and mentors. Due to the high level of responsibility each PAL must assume, a careful and systematic selection process will be utilized.

A PAL candidate should demonstrate the potential to be a good listener and leader. He/She should be trustworthy, honest, caring and dependable. Due to the nature of many PAL projects, the candidate should be a self-starter and one who is committed, motivated, flexible, and positive. The only grade requirements for a PAL candidate is that he/she consistently pass all of his/her courses. Because of the flexible grade requirement, the character of the candidate is the deciding factor on whether or not the candidate is the best choice for placement in the PAL class.

Please take a few moments to carefully fill out the recommendation form and feel free to write any additional comments in the space provided.


1. Student is a positive influence/role model 1 2 3 4

2. Student is prepared for class daily 1 2 3 4

3. Student is cooperative 1 2 3 4

4. Student is respectful to peers and teachers 1 2 3 4

5. Student is compassionate to others 1 2 3 4

6. Student can accept and give criticism 1 2 3 4

7. Student can handle leadership role 1 2 3 4

8. Student goes above and beyond required assignments 1 2 3 4

9. Student is an excellent peer helper 1 2 3 4

Total Score ______

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10. Student would be overloading self and schedule if accepted into the PAL class: (circle one choice)

______a. No, they will have enough time

______b. Yes, they will be busy but can handle the responsibility

______c. Yes, they already have too many other commitments

Additional comments:


This recommendation should be returned to _______________, PAL teacher,
by _________________. This recommendation can also be placed in the PAL teacher’s
school mailbox or returned to Room # ___________.

Page 5

Rules for Peer Assistance and Leadership Class

(Members are to be the example, not the exception, of all school rules)

  1. NO ISS First offense is a warning. Second offense will result in immediate removal.

  1. NO INSUBORDINATION toward teachers and/or other administrators and staff. Result is immediate removal.

  1. NO LEVEL 3 DISCIPLINE OFFENSE Result is immediate removal.

  1. NO SMOKING, ALCOHOL, DRUGS or WEAPONS Result is immediate removal.

  1. NO CAEP or DAEP Result is immediate removal.

  1. NO FIGHTING Result is immediate removal.

  1. NO SUSPENSION OR EMERGENCY REMOVAL Result is immediate removal.

  1. MUST FULFILL ALL OBLIGATIONS set by the PAL group, including but not limited to projects, workshops, and mentoring responsibilities. Failure to fulfill required duties and obligations will result in loss of points in participation grades and/or immediate removal.

  1. NO UNEXCUSED ABSENCES FROM PAL CLASS Result is immediate removal.

I have read and understand that PAL students are to adhere to the Code of Conduct listed above and realize that a violation will result in immediate removal.

__________________________ __________________________
Parent signature Date Student signature Date
Revised/Approved: Aug. ‘09

Page 6

Interview Questions

*You will be asked to answer five of these questions during your interview. Please look over these questions and be prepared with your answers. You may not use this paper or read written answers during the interview.
Applicants will be asked FIVE of the following questions! The questions will be the same for all applicants. (confidentiality will be discussed with each applicant after their interview)

  1. In what way, or in what ways, do you see yourself as a leader?

  2. As a PAL, you would be a role model for younger students and your peers. Why do you think you would be a good role model?

  3. What three qualities do you look for in a friend?

  4. What are some things you do to help someone trust you?

  5. What do you like about yourself?

  6. What is a good listener?

  7. Have you ever broken a confidence? What happened?

  8. What does the word commitment mean to you?

  9. What does the word confidentiality mean to you?

  10. Tell us about a time in your life when you made an impact on someone else’s life.

  11. What would you do if you didn’t get along with one of the other PALs that you had to work with?

  12. Why is it important to get to know other PALs?

  13. If you could change one thing about the world, what would you change and why?

  14. What is your biggest fear?

  15. Tell us about your favorite family tradition.

  16. Where do you see yourself in 10 years?

  17. What mistakes in life have you learned from?

  18. What is your biggest regret?

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