Mental Health Substance Abuse

C ross the Line (XLT)

Please bring this application with you on the day of your interview. Please write as clearly as possible.

Preferred

Name Moeshay York

First Last

Age 17 Grade 12th School Highland Park Renaissance Academy

Race African American Gender F Street Address 18w.longwood pl

City Highland Park

County United States Zip Code 48203 Primary Phone # 313-***-**** Email acxnvu@r.postjobfree.com Please describe any previous theater or acting experience: I do not have any previous theater or acting experience. Are you comfortable speaking in front of a group or audience? YES NO*

Cross the Line (XLT) meets T uesdays & Thursdays 4-7p. Are you available to meet at this time?

YES* NO

Can you get to and from Affirmations community center for meetings each week? ( W e are located at 290 W. 9 Mile, Ferndale) *Transportation stipends will be given monthly.

YES* NO

Are you willing to make a serious commitment to being a Cross the Line Peer Educator? T his includes committing to attending meetings EVERY week. Peer Educators will also be expected to make themselves available for at least 5 performances (most will be weekdays after school).

YES* NO

What other activities, if any, are you involved in? Please include days and times of those activities also.

Federal, State, and/or County funding has been provided through the Oakland County Community Mental Health Authority to support the project costs. Recipients of substance abuse prevention services have rights protected by state and federal laws and promulgated rules. For information contact the Oakland County Community Mental Health Authority Recipient Rights Coordinator, 2011 Executive Hills Blvd, Auburn Hills, Michigan 48326.

Contact this candidate