Name ______________________________________ ID Number __________________
Partner PE Application/Questionnaire
1. Why would you like to be a peer helper?
2. Have you ever worked around learners with disabilities (besides family)?
3. What does taking initiative mean to you?
4. Can you maintain confidentiality on a daily basis? Yes / No
5. What would you do if your peer partner(hit, bit, sniffed or licked) you?
6. Can you follow the expectations below? Yes / No
Focus on students with disabilities_______
Uphold students confidentiality________
Be on time to each class ________
Maintain a positive attitude_________
Stay active and on task with your partner________
Set a good example_________
7. What are three qualities you possess that would make you a good candidate for this class?
8. List two teachers who have agreed to be a reference for you:
Please initial the following:
_____ I understand that this class will take the place of another elective.
_____ I understand that participation in this class is contingent upon my behavior in and out of the classroom.
_____ I understand there is an interview component
________________________________________ ______________________
Student Signature Date
________________________________________ ______________________
Parent Signature Date
Best contact method: Phone ( ) - email .
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