Living Beyond Belief HIV/AIDS Peer Empowerment Program

LIVING BEYOND BELIEF IN MEMORY OF WAYNE FISCHER www.livingbeyondbelief.org

HIV/AIDS Peer Empowerment Program Criteria and Application

Program Mission: The HIV/AIDS Peer Empowerment Program was created by youth to inspire and encourage their peers to participate in activities that foster healthy self esteem and self appreciation. We strongly believe youth are a necessary catalyst for change, not only for their peers, but also for their communities, our country and our future generations.

Program Description: New York City Public High Schools that choose to participate in our HIV/AIDS Peer Empowerment Program will be provided with three certified HIV/AIDS peer educators all of whom have participated in an array of training including, HIV/AIDS Testing, NYC Health Services, Confidentiality, Pediatric HIV treatment, STD’s, OB/GYN Care, etc.

Our Peer Empowerment Educators will work with fifteen students that have been chosen by our internship/program committee to participate in this program. Each student who participates in the program will receive twelve formal 90- minute weekly training sessions with a core HIV/AIDS component.

The goal of the program is for each participant to use the knowledge that the peer educators have given them and to work with their group members to develop and implement a HIV/AIDS prevention project that will educate students at their school AND coordinate and facilitate a HIV/AIDS Education/Awareness workshop for students/teachers at their school.

Program Requirements: All applicants must:

 Be recommended by faculty  Have previous leadership experience  Express an interest in HIV/AIDS and youth  Be in good standing with the school (e.g. attendance)  Have the time and ability to attend 12 formal 90-minute weekly training sessions. Attendance at all 12 trainings is mandatory.  Commit to completing an HIV/AIDS education/prevention project AND participate in a workshop at their respective schools.

Program Rewards: Upon successful completion of the Peer Empowerment Program, students can expect to be:

 Inspired to make a difference  Empowered to effectuate positive change in the world  Awarded with a certificate of completion  Provided with a recommendation  Professionally trained in HIV/AIDS Peer Empowerment  Granted a stipend HIV/AIDS Peer Empowerment Program Application

STEP 1: INFORMATION (please print) A) Applicant’s Personal Info Name: ______Email: ______Social Security Number: ______Birthday: ______Home Mailing Address: ______Home Phone: ______Mobile/Alt. Phone: ______What is the best way to contact you? ______How did you hear about the Program? ______

B) Applicant’s High School/Organization’s info: Name of High School/Org.: ______Mailing Address: ______Phone:______Fax: ______Adult Contact: ______Adult E-mail: ______What is the best way to reach the Adult Contact? ______

STEP 2: ESSAY Please provide us with a 2 page personal statement, double spaced, using #12 size, Times New Roman font with one inch margins on the top, bottom, left, and right. Your essay should describe your leadership activities and your future goals. Be sure to include any extracurricular activities, events, organizations or conferences in which you have actively participated.

You MUST address: (i) why out of ALL the issues facing youth today you want to focus on HIV/AIDS; (ii) how you plan on continuing your HIV/AIDS related work after completion of our program, AND

 How you plan on empowering others to understand or address HIV/AIDS in their communities.  How you think you can apply the skills you have learned in your leadership role as an HIV/AIDS peer educator, advocate or activist to other youth related issues of concern in your community.

STEP 3: RECOMMENDATION A) Obtain at least 1 written recommendation:  From a teacher or an adult advisor who is aware of and supports your commitment towards HIV/AIDS education. B) Recommenders must include the following in their letters:  What is your relationship to the applicant?  How long have you known the applicant?  Why you believe the applicant should be chosen for this program.  Mailing address, cell phone, or email address. D) Recommenders may be called to verify the information they provide.

STEP 4: RELEASE FORM

 Applicant must sign the release form attached below.  If applicant is 18 years of age or younger, then the parent or guardian must sign the release attached below.

STEP 5: SUBMIT APPLICATION A) We strongly encourage you to attach any relevant work to your application (e.g. dvd’s/cd’s/photos).

B) Please submit two copies of your entire application before the January 15, 2008 deadline to: Dawn Robertson ATTN: Living Beyond Belief Peer Empowerment Program HSMSE @ CCNY Baskerville Hall 240 Convent Avenue New York, NY 10031

C) Checklist: 2 page personal essay. 1 or more recommendation(s). Parent/Guardian Release Form (necessary if 18 years of age or younger). All contact information is filled out in Step 1. 2 copies of your entire application (including recommendation). Post-marked by January 15, 2008.

D) Finalists will be interviewed by the internship/program committee.

Please Note: Once notified of selection into this program you have no later than Wednesday February 13, 2008 to accept induction. Winners must provide Living Beyond Belief with all requested follow-up information (for example a picture and short bio for our website), otherwise Living Beyond Belief shall maintain the discretion to provide such internship to the next runner up. Stipend and Certificate of completion is contingent on your attendance and participation throughout the 12-week program. RELEASE INFORMATION WAIVER FORM

A.) Applicant’s info:

Name: ______Email: ______Home Mailing Address: ______Home Phone: ______Mobile/Alt. Phone: ______

Date of birth (mth/day/year): ______Age: ______Sex/Gender: ______

B.) Parent or Guardian’s Info (needed if applicant is under 18 years of age):

Name: ______Email: ______Home Mailing Address: ______Home Phone: ______Mobile/Alt. Phone: ______

Relationship to Applicant: ______

Emergency Contact (if different from parent/legal guardian): ______

GENERAL RELEASE FORM FOR MINORS

Living Beyond Belief is a non-profit organization created to carry out the legacy of Wayne Fischer. As part of its outreach, educational and awareness program, Living Beyond Belief, may seek to audio tape, videotape, and/or photograph grant recipients to be used to further the organization's mission, which is to save lives by fostering HIV/AIDS prevention education, raising HIV/AIDS awareness and motivating NYC public high school students to be HIV/AIDS peer educators, advocates and activists by providing them with college grants, recognition and support for their life-saving work.

Living Beyond Belief assumes that by giving your child permission to be audio taped, videotaped, and/or photographed that you are supportive of the work that your child does in the area of HIV/AIDS education and awareness and that you see the value of providing this information to peers, individuals living with HIV/AIDS, the organizations supporters and similar parties.

CONSENT AND RELEASE FORM:

I hereby grant to Living Beyond Belief, the absolute right, for as long as often as they may elect, to copyright and/or use and/or publish in video, audio, print, or any other media, my name and/or likeness and/or statements, in whole or in part, for purposes of public education and information. I grant these rights in perpetuity for use in news, education, art, or any other lawful purpose whatsoever.

I waive any right to inspect and/or approve any related products that Living Beyond Belief may develop or the use(s) to which they may be applied. I also hereby release Living Beyond Belief from any and all claims relating to or arising from the uses consented to above. I understand that under no circumstances shall I have any right to maintain any cause of action against Living Beyond Belief by virtue of this agreement, the use of my name, likeness, and/or statements, or anything done pursuant here to.

I hereby have read this consent and release form, fully understand its contents, and agree to its terms knowingly and voluntarily.

______.

Signature of applicant Date

I hereby understand and agree to the above. ______.

Signature of parent/legal guardian Date

HIV/AIDS Peer Empowerment Program Recommendation

This checklist is to be prepared by candidate’s teacher and/or counselor

NAME ______Grade Level ______GPA ______

(Circle rating for each item, 1= poor/unsatisfactory, 10 = excellent)

Organize and carry out programs 1 2 3 4 5 6 7 8 9 10 Willingness to follow 1 2 3 4 5 6 7 8 9 10 Ability to lead 1 2 3 4 5 6 7 8 9 10 Responsibility 1 2 3 4 5 6 7 8 9 10 Tendency to exceed what is required 1 2 3 4 5 6 7 8 9 10 Initiative 1 2 3 4 5 6 7 8 9 10 Promptness 1 2 3 4 5 6 7 8 9 10 Ability to share knowledge 1 2 3 4 5 6 7 8 9 10 Interest in helping others 1 2 3 4 5 6 7 8 9 10 Attitude 1 2 3 4 5 6 7 8 9 10 Ability to articulate 1 2 3 4 5 6 7 8 9 10 Creativity 1 2 3 4 5 6 7 8 9 10 Cooperate with peers 1 2 3 4 5 6 7 8 9 10

 How long have you known the applicant and what is your relationship to the applicant? ______

 Why do you believe the applicant should be chosen for this program? ______

COMMENTS:______

______Signature Phone Number

Please staple or tape shut or place in envelope and deliver to Ms. Dawn Robertson, Guidance Counselor Baskerville Hall