AAMP Mentor Application

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Shannon Bates
5 years ago
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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.

1 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 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 Female Prefer not to disclose (I identify as): Address: 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? 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 1

2 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 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 2

3 If yes, for how long? What was the nature of your work or business? Areas of expertise /experience (please check all that apply): EMPLOYMENT Resume development Interview coaching Job search strategies Job coaching (support) Application process and paperwork Enhancing work skills SELF EMPLOYMENT/BUSINESS OWNER Starting a Business Business planning IT Support Legal issues Planning and organizing Budgeting Customer service Selling/Sales Project management Negotiation/Persuasion Creativity Problem solving Time management Leadership SPECIAL INTERESTS Hobbies (for example, comic collecting) Please specify Creative pursuits (for example, knitting) Please specify History (please specify) Building things (please specify) Sports (please specify) Movies/TV (please specify) Computers/IT (please specify) Games and other leisure pursuits (please specify) 3

4 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 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: 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: 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 Do you have any family members with ASD? Yes No If so, what is your relationship with them? 4

5 How would you rate your experience with ASD? (please check all that apply) Excellent - I have personal lived experience Excellent I live with someone who has ASD Excellent I work in the field of autism (please specify your role) Good I know someone with ASD quite well Fair I have a basic understanding of ASD I have known people with ASD Poor I have no experience whatsoever with ASD How would you rate your knowledge of ASD? (please check all that apply) Excellent - I have personal lived experience, or know someone close to me with ASD Excellent I have studied extensively in the field of autism Excellent I work in the field of autism (please specify your role) Good I have learned a lot about ASD (please specify where) Fair I have a basic understanding of ASD Poor I have little to no understanding of ASD In your opinion, what are some challenges that you anticipate in working with someone who is on the autism spectrum? What are some of the highlights you anticipate, in working with someone on the autism spectrum? What motivated you to apply to be involved in the AAMP Program? How did you hear about the AAMP Program? Are you currently an Autism Edmonton member? Name: Date: Signature: 5

P2P Mentor Program Application (Parent to Parent Mentor Program)

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