PeerCorps 2019 Mentee Application: Detroit

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Thank you for your interest in PeerCorps. If you're looking for an unique service or B mitzvah program that allows you to pursue social justice rooted in Jewish values--you've come to the right place. This application is for the Mentee cohort, grades 6th-8th.

B Mitzah age students commit to eight sessions at a grassroots service organization from either September-December (Fall) or March-May (Spring) sessions. In addition to the seven service sessions, all Mentees will need to attend one orientation session per cycle. Mentees work and learn alongside Mentors with built-in reflection and learning around their service issue areas. Mentee are typically between 6th and 8th grade.

Questions? Please don't hesitate to email Hannah Forman at peercorpsdetroit@weRepair.org.

Applicant's Contact Information

First Name

Last Name

Email

Please provide the applicant's email here only. The parent's email will be requested later in the application.

Cell Phone (Optional)

Birthdate

B Mitzvah Date

Congregation Name (If Applicable)

If your congregation isn't appearing as a suggestion, simply type it in.

Current Grade Level

Applicant's Address

Street Address

City

State

Zip Code (5 Digits)

If you have any questions, please write to Hannah Forman, peercorpsdetroit@werepair.org with questions.Thank you so much for your interest.

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PeerCorps Interest

When are you interested in participating with PeerCorps Detroit? Select one or both.

Fall 2019Spring 2020

What Detroit Fall sites are you interested in? Please rank your choices.

	1	2	3	4
Coleman A. Young Elementary School - Mondays, 4:00-7:00 PM
Georgia Street Community Collective - Thursdays, 4:00-7:00 PM
NewLEAF Detroit - Sundays, TBA timing
Yad Ezra - Wednesdays, 4:15-6:15 PM

What Detroit Spring sites are you interested in? Please rank your choices.

	1	2	3	4
Coleman A. Young Elementary School - Mondays, 4:00-7:00 PM
Georgia Street Community Collective - Thursdays, 4:00-7:00 PM
NewLEAF Detroit - Sundays, TBA timing
Yad Ezra - Wednesdays, 4:15-6:15 PM

Why are you interested in PeerCorps and/or the specific site(s) you checked above?

Why are you interested in participating in PeerCorps in general? Please write a short paragraph.

Tell us about an issue in your community or region that you feel passionate about. What solutions can you envision?

Do you have any food allergies or dietary restrictions?

Is there anything else you'd like us to know? Please include any accommodations you may need to participate fully in the program.

IDs

Community ID

Adult Information

Please provide contact information for this applicant's parent/guardian(s).

First Parent/Guardian's Information

First Name

Last Name

Email

Cell Phone (Optional)

Birthdate

I want to provide information for an additional parent/guardian

Second Parent/Guardian's Information

Adult 2 First Name

Adult 2 Last Name

Adult 2 Email

Adult 2 Cell Phone (Optional)

Birthdate

Wrapping Up

Other, please elaborate:

Please provide any questions or comments you have.

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Program Fee

We are so excited that you or your family is participating in Repair the World Detroit PeerCorps programming. We are grateful for your support and your family's desire to serve.

To ensure the sustainability of the program, we ask all of our families to make a payment for one cycle of $200, or $350 for the full year.

For those with more resources, we ask for you to consider giving more so as to make possible the participation of a child from a family who otherwise would not be able to.

For those for whom the full fee represents a financial hardship, please make a contribution that works for your family, and we will provide a scholarship for the rest.

Payment Plan

One Cycle $200Full Year $350Partial Payment

Partial Scholarship Amount

Your Family's Program Fees

Amount:

I would like to make an additional donation to go towards a scholarship fund for ensuring all who want to can participate.

Amount of Donation:

PeerCorps t-shirts are available for your child at a cost of $17. Would you like to purchase a PeerCorps t-shirt?

Yes, I would like to purchase a t-shirt

T-Shirt Cost

Would you like to cover the credit card processing fee of 2.5%?

YesNo

Credit Card Processing Fee

Total Amount of PeerCorps Payment

PeerCorps Detroit 2019-2020 Parent Campaign

Payment Information

I am the cardholder

Cardholder First Name

Cardholder Last Name

Billing Email

Cardholder First Name

Cardholder Last Name

Billing Email

Card Number

MM

YY

Code

Credit Card Type

Repair the World email	Friend colleague or relative	Repair the World service project	Facebook or Twitter
Internet search	Email from another organization	Other