2010 Peer Leadership Application Form

The Youth Hate Crime Prevention Peer Leadership Program is a collection of dynamic youth of different races and sexual orientations from San Francisco.

Participants will have the opportunity to learn and discuss issues of discrimination, harassment, racial violence, hate crimes, and tensions in their schools and communities.

Led by local experts, youth will participate in two hour workshops spanning eight weeks. You will learn to advocate for positive change in your schools by being role models. In effect, you will educate your peers about bigotry and acts of youth violence or intimidation based on race, gender, sexual orientation, or other differences.

Opportunities will be provided for you to set your own program goals relating to projects and to practice skills learned in real life settings. Food will be served at workshops. Bus Tokens will be distributed for transportation and other materials will be provided. Additionally, a $380 stipend and a Certificate of Recognition will be awarded to successful participants by the district attorney.



First Name: Last Name:

Grade: Age: Race/ Ethnicity:

Birthday: ( Write in format as MM/DD/YY)


City: State: Zip Code:

Home Phone: Cell Phone: Phone number examples 111-222-3333

email: Sexual Orientation:

Anything else you would like for us to know about you?

Can we contact you? If yes, what is the best time to reach you?

Please answer the following questions; if your answer does not fit in the space provided you may send additional information to There are no right or wrong answers.

1. Why are you interested in serving as a hate crime prevention peer leader?

2. What makes you a good peer leader? How have you shown leadership? (Example: community service, leading school project, etc.)

3. Have you been harassed or discriminated* against? How did you feel? What did you do about it?

4. How accepting is your school re: the group of students below? (1=very uncomfortable, 10=very comfortable).

African American
Arab/Middle Eastern
Asian/Pacific Islander

What, if anything, do you think the school or students could do to help alleviate the problem?

5. Please tell us something unique about yourself.

6. Please list your skills and or hobbies that might make you an effective leader.

7. What are your career goals for the next 5 years & 10 Years.

8. Reference:
Please provide contact information for a reference that knows about your work or your abilities as a youth leader. It can be a peer, friend, teacher, or anyone familiar with you.

Name: Relation to you:

Phone: (example 111-222-3333) Reference's email:

Click SUBMIT to send your information electronically to our offices for processing. Your information is being sent through our secured site to the staff for secure handling. Please print this page for your records before submitting.

If you have questions or need help filling out the application, please contact us at 415-643-1400,, or talk to a teacher, counselor trusted friend or adult. Thank You and Good Luck!

* Harassment occurs when someone’s behavior or language creates a hostile, offensive or intimidating environment. A single incident depending on its severity may constitute illegal harassment. Examples are:
• Demeaning or abusive verbal statements or writings of a sexual or racial nature, i.e., related to a student’s race, ethnic background, gender, sexual orientation;
• Graffiti, slogans or other visual displays that contain racial, ethnic slurs or insults based on the student’s gender, sexual orientation, or disability;

* Discrimination: Every student is entitled to equal educational opportunities. A student may not be subjected to discipline or punishment for wrongdoing nor denied the same rights as other students because of his or her race, ethnic background, gender, sexual orientation, or disability.

The Youth Hate Crime Prevention Peer Leadership Program is a collaborative initiative between the District Attorney’s Office, Bar Association of San Francisco., Department of Justice, Gay-Straight Alliance Network, Community Youth Center, United Playaz, Brothers Against Guns, Boys and Girls Club-Columbia Park, and other community organizations.

Applications must be RECEIVED by Friday, January 31, 2011; 5:00 p.m.
Renaissance Parents of Success
1800 Oakdale Room 510, San Francisco, CA 94124