Amachi Mentor Application Amachi Mentor Application Thank you for your interest in becoming an Amachi mentor! Please complete this application to determine your eligibility for the program. Should you be approved, your responses will help us match you with a suitable mentee. All information provided will be kept strictly confidential.Contact InformationName First Last Today's Date Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Date of Birth AgeSexMaleFemaleDriver's License NumberCar Insurance ProviderPolicy NumberPlease provide your contact information.Home PhoneCell PhoneWork PhoneEmail What is your preferred method of communication?No preferenceHome phoneCell phoneWork phoneEmailPersonal/Demographic InformationRace (select all that apply)CaucasianBlack or African AmericanAmerican Indian or Alaska NativeAsianNative Hawaiian or Other Pacific IslanderOtherAfricanBiracialHispanic or LatinoOther (Race)Marital StatusSingleMarriedDomestic PartnershipSeparatedDivorcedWidowedIf married, list your spouse's name.How many people live in your household?Note: all household members over the age of 18 will be required to submit clearances.Do you currently have any children living with you?YesNoIf yes, please list their name(s), age(s), sex(es), and relationship to you (e.g., children, step-children, foster children, nieces).Does your family support your decision to mentor the child of an incarcerated individual?YesNoDo you currently attend a congregation or adhere to/practice a religion?YesNoIf yes, please list your congregation or affiliation.Do you expect to undergo changes, such as the following, within the next year (select all that apply)?Change in Marital StatusChildbirthEducational PursuitsChange in ResidencyOtherOther (Life Changes)Have you ever been convicted of a crime?YesNoIf yes, please explain.Have you been cited for any moving traffic violations within the last year?YesNoIf yes, please explain.Employment InformationAre you currently employed?YesNoRetiredIf yes, list the name of your employer.Are you full-time or part-time?Full-timePart-timeDoes your job require you to travel?YesNoIf yes, how often?Educational BackgroundCheck the highest level of education you have completed. Some High School High School Graduate General Equivalency Degree (GED) Some College Associate's Degree Bachelor's Degree Vocational/Technical School Master's Degree Doctorate or other Professional Degree Other Other (Level of Education)Please list any training or certifications you think will inform your role as a mentor (particularly youth-related training).Activities/Interests: Select as many activities from the list below that interest you. Arts/Crafts Cooking/Eating Out Theater Playing Sports Computer/Video Games Dance Concerts Movies Museums Travel Shopping Listening to Music Biking Reading Watching Sports Photography Volunteering Please list other activities of interest not listed above.Emergency Contact InformationPlease list two people we could reach out to in the event of an emergency.Emergency Contact 1 First Last Emergency Contact 1: Relationship to youEmergency Contact 1 PhoneEmergency Contact 2 First Last Emergency Contact 2: Relationship to youEmergency Contact 2 PhoneQuestionnaireWhat has inspired you to become a mentor?Do you have previous experience working with youth?Would you be able to meet with your mentee for a minimum of 4 hours per month?YesNoPlease indicate your first, second, and third age-range preferences for your mentee.4-6Please enter a value between 1 and 3.7-9Please enter a value between 1 and 3.10-12Please enter a value between 1 and 3.13-18Please enter a value between 1 and 3.No preferencePlease enter a value between 1 and 3.What qualities draw you to the age group you chose as your first preference?Please indicate if you would like to mentor a child with a particular race, ethnicity, or religious affiliation, and why.What are three characteristics you'd like your mentee to have?Would you be willing to work with a mentee with a physical and/or intellectual disability?YesNoIf yes, please specify which types of disabilities you would be comfortable working with.If you can speak any other languages other than English, please list them here.Rank the following with the number best describing your willingness and/or ability to cope with some of the issues that may be present in a match using the following scale: 1 = I am willing to cope with this as a consistent problem area. 2 = I am willing to cope with this as a mild or occasional problem area. 3 = I am unwilling to mentor a child with this problem.HyperactivityPlease enter a value between 1 and 3.ADDPlease enter a value between 1 and 3.IndifferencePlease enter a value between 1 and 3.DepressionPlease enter a value between 1 and 3.Sexually ActivePlease enter a value between 1 and 3.Poor HygienePlease enter a value between 1 and 3.Foster PlacementPlease enter a value between 1 and 3.Learning DisabilityPlease enter a value between 1 and 3.Autism SpectrumPlease enter a value between 1 and 3.WithdrawalPlease enter a value between 1 and 3.Dirty Home/HoardingPlease enter a value between 1 and 3.Lying and/or CheatingPlease enter a value between 1 and 3.StealingPlease enter a value between 1 and 3.SmokingPlease enter a value between 1 and 3.Consuming AlcoholPlease enter a value between 1 and 3.Using the same scale, please rate your willingness to cope with the following issues regarding the child's environment.Court Involvement/CYFPlease enter a value between 1 and 3.Parental Drug/Alcohol UsePlease enter a value between 1 and 3.Lack of Parental InvolvementPlease enter a value between 1 and 3.Please list the neighborhood(s) or zip code(s) where you would prefer your mentee to live (we recommend no further than 30 minutes from your home).CaptchaThank you! A member of the Amachi Pittsburgh team will be in touch.