P2P Mentor Program Application (Parent to Parent Mentor Program)

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Annabella Jenkins
5 years ago
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1 P2P Mentor Program Application (Parent to Parent Mentor Program) Thank you for your interest in volunteering with us in the P2P Program Pilot! Autism Edmonton has consulted potential mentees in a survey and focus group setting and their feedback is reflected in this application form. In an effort to successfully match mentors and mentees, we are asking you to provide demographic information in the following pages. Please answer the following questions truthfully. Personal Information First name: Last name: Date of Birth (Year): Gender: Male Address: Female Transgender (I identify as): City: Province: Postal Code: Day phone: Evening phone: Please select the culture/ethnicity you identify with most: Canadian Filipino Asian (all other) French Canadian Central American South American First Nations Metis African Eastern European Western European European (all others) Middle Eastern Pacific Island Asian (all other) Southeast Asian Prefer not to answer Language(s) spoken: Were you born in Canada? Yes No If not, when did you come to Canada? 1

2 Location I LIVE in this part of the city: North East North West North central South East South West South central Sherwood Park St. Albert Spruce Grove/Stony Plain Beaumont Leduc I WORK in this part of the city: North East North West North central South East South West South central Sherwood Park St. Albert Spruce Grove/Stony Plain Beaumont Leduc Transportation : Driving by car I drive my own car I drive and have access to a car I do not drive Edmonton Public Transit I am knowledgeable and comfortable with ETS buses I am comfortable with ETS buses I am not comfortable with ETS buses I am knowledgeable and comfortable with LRT I am comfortable with LRT I am not comfortable with LRT Other bus systems (Sherwood Park, St. Albert) I am knowledgeable and comfortable with other bus systems I am comfortable with other bus systems I am not comfortable with other bus systems Taxi or Ride Sharing I am comfortable taking a taxi or ride sharing services I am not comfortable with taking a taxi or ride sharing services I am not comfortable with taxis or ride sharing services Other methods of transportation I ride my bike I walk 2

3 Employment Information Are you currently employed? Yes No Company/Organization Name: Role: If no, then when were you last employed? For how long? Have you ever been self-employed? Yes No If yes, for how long? What was the nature of your work or business? Areas of expertise /experience (please check all that apply): EDUCATION Funding Education options Preschool programs Specialized programs Public school system Catholic school system Private school system Home schooling Education and dispute resolution Other school programs Socializing in school Other educational programs PERSONAL and RESOURCE INFORMATION Challenges of parenting a child with special needs Sibling relationships Behaviour concerns Advocating for your child Dealing with other family members Self-care Finding a doctor/dentist/hair stylist, etc. Finding service providers Finding other programs 3

4 TRANSITIONING Starting school for the first time Starting Junior high school Starting Senior high school Leaving High school Starting work or volunteering Leaving home Moving (from house to house, to another city, etc.) Changes in relationships Divorce Bereavement SOCIAL SUPPORT Going to special events or festivals Going to movies Going to trade fairs/conventions Going out for dinner or coffee Going to Edmonton attractions Going to libraries, museums, etc. Going to the gym Playing sports Playing board games or computer games Going to hear speakers, presentations Education Please indicate your highest level of completed education: High School Vocational Training Some post-secondary College Diploma University Degree Masters PH. D Name of diploma/degree: Are you currently attending school? Yes No Course of study: 4

5 Volunteer Information Have you ever volunteered in a mentor program (of any kind) before? Yes No If yes, please provide name of organization and dates: Have you ever volunteered (or worked) with persons with autism before? Yes No If yes, please provide name of organization: Your role: Dates: Experience with Autism Spectrum Disorder (ASD) Have you been diagnosed with ASD? Yes No If no, do you suspect that you have ASD? Yes No If Yes, what are some of the challenges that you have faced as an individual with ASD? If Yes, What are some of the benefits you ve experienced because of your autism? Besides your child, do you have any other experience with ASD? Yes No If Yes, please explain: What motivated you to apply to be involved in the P2P Program? How did you hear about the P2P Program? Are you currently an Autism Edmonton member? 5

6 About Your Mentee For EACH statement, please indicate your level of agreement with the following statements: Statement An absolute MUST Preferred Not important No My mentee s child has to have ASD in the same severity as my child My mentee also has an ASD diagnosis My mentee is married My mentee is in a relationship My mentee is a single parent My mentee is in a blended family My mentee is the same gender as me My mentee speaks another language My mentee is a newcomer to Canada My mentee was a newcomer to Canada My mentee works full time outside the home My mentee works part time outside the home My mentee is a stay at home parent My mentee wants to include our children whenever we get together. My mentee has knowledge of autism besides their experience with their own child (eg. education, professional, other family member) My mentee should be within 5 years of my own age. My mentee should live within the same area of the city as me (for eg. south east, central, north east, north west, south west) My mentee should have a similar level of faith as me and/or my family. My mentee must have access to . My mentee has to have a similar belief in ASD treatments and interventions as me Name: Date: Signature: 6

AAMP Mentor Application

AAMP Mentor Application (Adults with Autism Mentor Program) Thank you for your interest in volunteering with us in the AAMP Program Pilot! Autism Edmonton has consulted potential mentees in a survey and