Reyburn Intermediate

Peer Counseling Class Application 6^TH GRADE STUDENT MOVING to 7^th GRADE

Applicant’s Name: ______________________	Elementary School: __________________

What is Peer Counseling?

Purpose: Peer Counseling is designed to teach basic counseling skills that enhance positive attitudes toward self and provide techniques that can be used to help other students build their interpersonal skills. In addition, communicate in appropriate ways and be connected to various school programs for assistance. It is part of the Health and Wellness Department of CUSD.

Student Training: Peer mediation, conflict resolution, team building, tutoring skills, nonverbal cues, nonjudgmental/empathetic responses, confidentiality, etc.

Some of Our Activities Include: one on one mediation, group mediation, buddy pairing, tutoring, ongoing weekly meetings with students in need, school events, classroom presentations etc.

As a member of this class you will be required to sign a code of ethics and confidentiality contract that will be strictly enforced. Peer Counseling is a yearlong elective and is open to those students of good character and have above a 2.0 grade point average. YOU MUST HAVE TWO TEACHER RECOMMENDATIONS. Please return your completed application to Amy Kilburn at Reyburn Intermediate. ********************************************************************************************************* Please answer the following questions in complete sentences:

1. Why would you like to be a Peer Counselor on the Reyburn Campus and what qualities do you have that will aid you in working with your peers? Please also include your definition of what it means to be inclusive rather than exclusive. _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________

2. Why is confidentiality important when being a Peer Counselor and why do you think that is an important element of Peer Counseling? _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________

3.	 What other activities do you plan on participating in during the 2017-2018 school year? _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________

Teacher Recommendation
YOU MUST HAVE TWO TEACHER RECOMMENDATIONS

Name of Recommending Teacher:         ________________________________________ (Printed Name)

________________________________________ (Signature)

Name of Student:	________________________________________

Dear Teacher;
As part of the application process for becoming a member of the Peer Counseling Program at Reyburn Intermediate School, it’s essential to have teacher input. This allows for an accurate a picture for each potential member. Please take a moment to review the statements below, and choose the option that best describes the student named above. Please note that we are looking for students of good character, and who are confidential with information. These students are trusted to work with other students, interact with staff, and represent Reyburn in a positive way. Please do NOT recommend a student who you’re not positive can handle this class. ALL EVALUATIONS ARE COMPLETELY CONFIDENTIAL AND WILL NOT BE AVAILABLE TO ANY CANDIDATE NOR THEIR PARENTS. Please feel free to add any addition comments.

All Teachers: Please mail this form to Amy Kilburn at Reyburn or return to Reyburn’s Main Office no later than March 23, 2018. If you prefer to return with a student, please make sure that it is sealed in an envelope.

Please circle which of the following traits this student demonstrates in your class (explain as necessary):

Student displays proper conduct and behavior
Always	Usually	Sometimes	Rarely	Never Student has good attendance
Always	Usually	Sometimes	Rarely	Never Student is courteous to others and respects peers as well as adults
Always	Usually	Sometimes	Rarely	Never Student is trustworthy and confidential
Always	Usually	Sometimes	Rarely	Never Student shows respect
Always	Usually	Sometimes	Rarely	Never

Please circle one of the following: I highly recommend this student

I recommend this student because they show potential to be a leader

I have some reservations about recommending this student

I have definite reservations about recommending this student

I do not recommend this student.

PLEASE FEEL FREE TO USE THE BACK OF THIS PAPER FOR ANY ADDITIONAL COMMENTS.

Teacher Recommendation
YOU MUST HAVE TWO TEACHER RECOMMENDATIONS

Name of Recommending Teacher:         ________________________________________ (Printed Name)

________________________________________ (Signature)

Name of Student:	________________________________________

Dear Teacher;
As part of the application process for becoming a member of the Peer Counseling Program at Reyburn Intermediate School, it’s essential to have teacher input. This allows for an accurate a picture for each potential member. Please take a moment to review the statements below, and choose the option that best describes the student named above. Please note that we are looking for students of good character, and who are confidential with information. These students are trusted to work with other students, interact with staff, and represent Reyburn in a positive way. Please do NOT recommend a student who you’re not positive can handle this class. ALL EVALUATIONS ARE COMPLETELY CONFIDENTIAL AND WILL NOT BE AVAILABLE TO ANY CANDIDATE NOR THEIR PARENTS. Please feel free to add any addition comments.

All Teachers: Please mail this form to Amy Kilburn at Reyburn or return to Reyburn’s Main Office no later than March 23, 2018. If you prefer to return with a student, please make sure that it is sealed in an envelope.

Please circle which of the following traits this student demonstrates in your class (explain as necessary):

Student displays proper conduct and behavior
Always	Usually	Sometimes	Rarely	Never Student has good attendance
Always	Usually	Sometimes	Rarely	Never Student is courteous to others and respects peers as well as adults
Always	Usually	Sometimes	Rarely	Never Student is trustworthy and confidential
Always	Usually	Sometimes	Rarely	Never Student shows respect
Always	Usually	Sometimes	Rarely	Never

Please circle one of the following: I highly recommend this student

I recommend this student because they show potential to be a leader

I have some reservations about recommending this student

I have definite reservations about recommending this student

I do not recommend this student.

PLEASE FEEL FREE TO USE THE BACK OF THIS PAPER FOR ANY ADDITIONAL COMMENTS.