Western Illinois University: Macomb Campus

Name: *

University ID#: * (XXX-XX-XXXX)

Current School Address: *

Phone: * (XXX-XXX-XXXX)

Permanent (Home) Address: *

City: *

State: *

Zip: *

E-Mail: *

Anticipated Graduation Date: * (MM/DD/YYYY)

College Major(s)

College Minor(s)

G.P.A.: *

What work experience, technical skills, volunteer experience, or community/campus (or high school) involvement have you had? (Please indicate any which you feel is applicable to the peer educator role.)

Why would you like to be a member of Students T.A.L.K.?

What are some of your leisure interests and activities?

How did you hear about Students T.A.L.K.?