Project Adventure Partners for Youth with Disabilities - Adult Application Thank you for your interest in Project Adventure. You have two options for completing this application: Apply online below and submit answers through this website Or, download application (.pdf file), print, complete and mail to: Partners for Youth with Disabilities 95 Berkeley St. Suite 109 Boston, MA 02116 Attn: Jenna Curry It is estimated that this application may take 10-30 minutes to complete. Please review the entire page before you start. Date of Application  Program  Name  Address  City  State  Zip  Home Phone  Work Phone  Cell Phone/Pager  Email Address  Current Employer/School  Length of Employment  Do you speak any foreign languages?  Do you have any special skills?  Do you have a driver's license?  Access to a car?  License #  Auto Insurance Company  OTHER HOUSEHOLD MEMBERS Name Age Gender Type of Job/School Relationship Describe the family in which you grew up (how many parents, siblings, family relationships and values).  How do you spend your leisure time (hobbies, interests, etc.)?  What is your history of community involvement and experience with youth programs?  Describe what kind of boy/girl would make the best match with you (age, group, disability, background, challenges, interests, careers goals, personality type, etc.).  How far are you willing to travel (time and/or specific areas)?  Why do you want to become a mentor for Partners for Youth with Disabilities?  Do you have any additional comments, information, questions you would like to share?  Do you feel that you can meet the minimum standard of having the following contact with your mentee:  Partners Online A) Email contact with a mentee twice a week? Yes No B) Chat or Instant Message contact with a mentee once a week? Yes No C) In person contact with a mentee at least 3 hours once every 3 months? Yes No D) Do you sincerely feel that you will be able to remain in the program for at least one year? Yes No Do you sincerely feel that you will be able to remain in the Project Adventure program for at least six months?  Yes No Have you ever been convicted of any offenses by civilian or military court?  Yes No Have you been or are you now being charged with any criminal offense, or are any civil court actions or judgment now being pending against you?  Yes No If you have answered "yes" to either of the above, please provide details on a separate sheet. State the date and place of each arrest, court action or judgment. Give the nature of the charge or court actions, and current status of diposition including any sentence or fine imposed. Provide a complete explanation of the circumstances.  Have you been treated for alcohol or drug dependency?  Yes No If yes, please list date(s) and place(s) of treatment.  REFERENCES Please list three (3) people who know of you and your interest in becoming a mentor whom we may contact by phone as references. Please include, if possible Current or most recent job supervisor and An individual who is not a close friend or relative Name Phone (W) Phone (H) How long known to you? Race  American Indian/Alaska Native Asian Black/African American Hispanic/Latino Native Hawaiian/Pacific Islander White/Caucasian Other  Marital Status  (ALL that apply) Married, spouse presen Married, spouse absent Unmarried, living with partner Widowed Divored Never married Other  What is your primary language spoken in your home?  What is your gender?  Male Female Have you had prior experience as a parent or guardian?  Yes No Have you had prior experience as a mentor?  Yes No What is your employment status?  Unemployed Employed Retired Student If not a student, which of the following best characterizes current or immediate past employment?  Managerial/Professional Technical/Sales/Administrative Service Military Law Enforcement/Justice Regilious Other  What is your highest level of education completed?  High School Diploma College Courses Associate's Degree BA/BS Degree MS Degree Doctoral Degree Other  What is the nature of your disability?  No Disability Physical Disability Blind/Low Vision Deaf/Hard of Hearing Learning Disability Cognitive Disability Other  If you checked more than one box above, what is your primary disability?  If applicable, what are the functional limitations of your disability? What accommodations are needed?  List all PYD programs you have participated in and the date(s) of your enrollment (Month/Year).  How many (if any) mentees have you been matched with and how long did each match last?  What is your primary reason for applying to be a mentor?  To give back to the community To support a child with a disability Had a positive experience with a mentor as a child PYD sponsored a community service project Experience for career/educational development Other  Final Acceptance of Terms: Who completed this application? Yes, the applicant completed this form. No, someone other then the applicant completed this form. If no, provide name:   Electronic Approval: Yes, I certify that all the statements made in this application are true, correct and complete to the best of my knowledge and are made in good faith. I understand that any misinformation may be cause for disqualification or termination. Signature of Applicant Date Review the entire form and confirm that all of your answers are correct. Print and file a copy of this application with your personal records.     PYD Adult Application Partners for Youth with Disabilities, 95 Berkley Street, Suite 109, Boston, MA, 02116 Phone: (617 556-4075 / TTY: (617) 314-2889 Copyright © 2008 Children's Hospital Boston