AMP Mentee Application Form – Autism Mentorship Program

Applicant Name *

First

Last

Pronouns *

Example: she/her, he/they

Date of Birth (month/day/year) *

Example: 01/01/2000

Gender Identity *

We are gathering this information because some mentees want to be matched with mentors that share similar gender identities.

Race/Ethnicity *

We are gathering this information because some mentees want to be matched with mentors that share similar racial/ethnic identities.

Does the applicant have proof of an official autism diagnosis? *

Yes, receiving special education (IEP) under the eligibility category of autism
Yes, received a formal diagnosis from a doctor, psychologist, therapist, etc.
I'm not sure; please follow up with me
No, self-diagnosed

For the purposes of our research study with the University of Minnesota, we require proof of an official autism diagnosis as a criterion to participate in AMP this year. We hope to expand to include self-diagnosis in the future.

Primary Guardian Name *

First

Last

Relationship to Applicant *

Guardian Email *

This is the email we will use to contact you. It should be an email that you can access regularly.

Guardian Phone Number *

This is the phone number we will use to contact you. It should be a phone that you can access regularly.

What are the best ways to contact your guardian? Please select all that apply. *

Email
Text
Phone call

Do you live in the 7-county Twin Cities metro area (Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, or Washington County)? *

Yes
No

Due to our limited resources, we can only allow Minnesota residents who live in the listed seven counties.

Street Address *

This includes your house number, street name, and apartment/unit number if applicable. This information will only be used to confirm that you live in Minnesota.

City, State, ZIP *

Applicants: Why do you want to participate in a mentoring program? *

Please have the APPLICANT complete this question (help from guardians/others is allowed, but the content should come from the applicant).

Are you available to meet with a mentor via Zoom every week during the upcoming school year for approximately one hour? *

Yes
No

Please list your availability after school and on weekends for a weekly 1-hour Zoom call during the school year. If you don't know, please indicate when you will have a finalized schedule. *

Can you commit to participating for a minimum of one school year? *

Yes
No

What questions do you have about the program? *

If you have questions after completing this form, you can email megan.perera@autismmentorshipprogram.org.

Guardians: By signing my name below, I consent to my child participating in the affiliated University of Minnesota evaluation study of AMP. I have read the information about the study listed below and understand that I will receive more information about the study in the future. *

AMP is partnering with the University of Minnesota to conduct a research study on the effectiveness of AMP for autistic people. Because this research is vital to the future expansion of AMP to other counties and states, we ask that all AMP mentees participate in the research study for the 2022-2023 program year.

Guardians: By signing my name below, I hereby grant permission for AMP to contact my child online to conduct a personal interview for the purposes of applying to be a mentee and for additional screening and ongoing participation in the mentoring program. *

By signing my name below, I consent to basic information about my child being shared with prospective mentor(s) after my child and I approve of the mentor. Once a mentor/mentee match is determined, relevant information about my child (excluding contact information for privacy protection) will be shared with the mentor to the extent it aids in facilitating a successful match. *

Where did you hear about AMP?