Date:
Adult Application
Contact Information
Name: Click or tap here to enter text.
Address: Click or tap here to enter text.
City, State, Zip Code:Choose an item.
Phone (home): Click or tap here to enter text.
Primary Email: Click or tap here to enter text.
Phone (work): Click or tap here to enter text.
Phone (cell): Click or tap here to enter text.
Background Information
Date of
Birth:
Select a Month.
Select a Day.
Race & Ethnicity
Select a Year.
Mark all that apply.
Asian
Gender Identity:
☐Male
☐Female
Black ☐
Optional
Hispanic/Latino ☐
If applicable, country/cultural
identity:
Middle Eastern ☐
Multiracial ☐
Primary language spoken: Choose an item.
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Native American ☐
Pacific Islander ☐
Foreign language(s) spoken: Click or tap here to enter text.
White ☐
Other:
_________________
Highest level of education completed: (select one)
Current employment status: (select one)
High School ☐
Unemployed ☐
College Courses ☐
Employed ☐
Associate’s Degree ☐
Retired ☐
BA/BS Degree ☐
Student ☐
Master’s Degree ☐
Other ☐
Doctoral Degree ☐
Current employer/school: Click or tap here to enter text.
Do you have a driver’s license? Choose an item.
Length of employment / year in school: Click or tap here to
enter text.
Do you own or have access to a car? Choose an item.
Marital status: Choose an item.
UCBLN-MentorABILITY-Match
236 9th Street, Evanston, Wyoming 82930
Phone: 307-783-6302
www.blnworks.com
adapted from Partners for Youth with Disabilities 2017
Date:
UCBLN-MentorABILITY-Match
Adult Application
Emergency Contact Information
Name: Click or tap here to enter text.
City, State, Zip Code: Choose an item.
Phone (cell): Click or tap here to enter text.
Relationship: Click or tap here to enter text.
Phone (alternate): Click or tap here to enter text.
Email: Click or tap here to enter text.
Do you identify as having a disability?
At MentorABILITY, we define “disability” very broadly, spanning from physical disabilities to learning disabilities to mental health and
health conditions. Many of our mentees are interested in being matched with someone with similar disabilities or challenges as
themselves, so the more we know about your background and desired accommodations, the better we’ll be able to find a match that’s
empowering for both sides.
Developmental
Autism spectrum ☐
Down syndrome ☐
Fragile X syndrome ☐
Sensory integration disorder ☐
Physical
Ataxia ☐
Cerebral palsy ☐
Muscular dystrophy ☐
Scoliosis ☐
Spina bifida ☐
Mental Health
ADHD ☐
Anorexia or bulimia ☐
Anxiety ☐
Bipolar ☐
Depression ☐
Obsessive-compulsive ☐
Post-traumatic stress ☐
Schizophrenia ☐
Intellectual
Brain injury ☐
Cognitive delay ☐
Learning
Auditory processing disorder ☐
Dyscalculia ☐
Dyslexia ☐
Non-verbal learning disorder ☐
Communication
Aphasia ☐
Language disorder (expressive or
receptive) ☐
Non-verbal ☐
Stutter ☐
Tourette ☐
Sensory
Hard of hearing or deaf ☐
Visual impairment or blind ☐
Health
Asthma ☐
Blood disorder ☐
Cancer ☐
Diabetes ☐
Epilepsy ☐
Immune disorder ☐
Other
Click or tap here to enter text.
If applicable, what are the functional limitations of your disability?
Click or tap here to enter text.
UCBLN-MentorABILITY-Match
236 9th Street, Evanston, Wyoming 82930
Phone: 307-783-6302
www.blnworks.com
adapted from Partners for Youth with Disabilities 2017
Date:
UCBLN-MentorABILITY-Match
Adult Application
What accommodations are needed (if applicable)?
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Primary Household Members
Name
Age
Gender
School/Job
Relationship
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enter text.
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enter text.
Choose an item.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
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enter text.
Choose an item.
Background Check
☐ Yes
Have you ever been convicted of any offense by civilian or military court?
☐ No
Have you been or are you now being charged with any criminal offense, or are any civil court actions or judgments now
pending against you?
☐ Yes
☐ No
If you answered “yes” 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 disposition including any sentence or fine imposed.
Provide a complete explanation of the circumstances.
☐ Yes
Have you ever been treated for alcohol or drug dependency?
☐ No
If yes, please list date(s) and place(s) of treatment: Click or tap here to enter text.
Mentoring Background
Have you had any prior experience as a parents / guardian?
Have you had prior experience as a mentor, through MentorABILITY or
elsewhere?
Have you participated in any other MentorABILITY program? If so, which
ones?
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Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
UCBLN-MentorABILITY-Match
236 9th Street, Evanston, Wyoming 82930
Phone: 307-783-6302
www.blnworks.com
adapted from Partners for Youth with Disabilities 2017
Date:
UCBLN-MentorABILITY-Match
Adult Application- Interview Questions
References
Name
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text.
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text.
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text.
Phone
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text.
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text.
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text.
Email
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Click or tap here to enter text.
Length known
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to enter text.
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to enter text.
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to enter text.
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.
Click or tap here to enter text.
Click or tap to enter a date.
Signature of Applicant
Date
UCBLN-MentorABILITY-Match
236 9th Street, Evanston, Wyoming 82930
Phone: 307-783-6302
www.blnworks.com
adapted from Partners for Youth with Disabilities 2017
UCBLN-MentorABILITY-Match
Adult Application- Interview Questions
Date:
Interview Questions
Describe the family in which you grew up (parents, siblings, family relationships, and values).
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How do you spend your leisure time (hobbies, interests, etc.)?
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What are the core aspects of your personal identity? Do you identify with any particular communities (i.e. cultural, ethnicity,
GLBTQ, disability, gender, career, interests or hobbies)?
Click or tap here to enter text.
UCBLN-MentorABILITY-Match
236 9th Street, Evanston, Wyoming 82930
Phone: 307-783-6302
www.blnworks.com
adapted from Partners for Youth with Disabilities 2017
UCBLN-MentorABILITY-Match
Adult Application- Interview Questions
Date:
What is your history of community involvement and experience with youth?
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Why do you want to become a mentor?
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How comfortable are you in working across differences (i.e. cultures, languages, abilities, sexual orientation)?
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Describe the characteristics of a mentee that would make the ideal match for you (i.e. age, disability, background,
interests, personality, etc.).
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How far are you willing to travel to meet with your mentee? And what’s your preferred mode of transportation?
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If your mentee could take away one thing from the program, what would that be?
Click or tap here to enter text.
UCBLN-MentorABILITY-Match
236 9th Street, Evanston, Wyoming 82930
Phone: 307-783-6302
www.blnworks.com
adapted from Partners for Youth with Disabilities 2017
Date:
UCBLN-MentorABILITY-Match
Adult Application- Interview Questions
Do you feel you can meet the minimum program requirements
(4-6 hours per month, weekly contact, one year)? Would you
be interested in continuing beyond the one year requirement?
What are your personal/employment goals for the coming year
and the next five years? Do you anticipate moving?
Would you be willing to work with a mentee that required more
in-person meetings (at least two per month)?
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Click or tap here to enter text.
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What are your best times for availability?
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SCENARIO: You’re matched with a mentee, but for the first month, you have a tough time engaging them. Your mentee
doesn’t call or email you without prompting, and for your first scheduled meeting, your mentee doesn’t show up at the
correct time. What would you do?
Click or tap here to enter text.
SCENARIO: You’re matched to a mentee and after getting to know each other for a few months, they come out to you as
gay. This was not something you knew going into the match. What would you do?
Click or tap here to enter text.
UCBLN-MentorABILITY-Match
236 9th Street, Evanston, Wyoming 82930
Phone: 307-783-6302
www.blnworks.com
adapted from Partners for Youth with Disabilities 2017
UCBLN-MentorABILITY-Match
Adult Application- Interview Questions
Date:
SCENARIO: You’re matched with a mentee, but after four months, you’ve found you have a ton on your plate. Your
responsibilities at work/school have increased, and it’s getting more and more difficult for you to meet with your mentee.
What would you do?
Click or tap here to enter text.
Do you have any additional comments or information to share? Any questions we didn’t ask that you wish we had?
Click or tap here to enter text.
UCBLN-MentorABILITY-Match
236 9th Street, Evanston, Wyoming 82930
Phone: 307-783-6302
www.blnworks.com
adapted from Partners for Youth with Disabilities 2017