AMP Mentor Application Form – Autism Mentorship Program

Today's Date (Month/Day/Year)

Example: 07/27/2023

Name *

First

Last

Pronouns *

Example: she/her, he/they

Email *

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

Phone Number *

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

What is the best way to contact you? 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.

City, State, ZIP *

Date of Birth (month/day/year) *

Example: 01/25/1989

Gender Identity *

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

Race/Ethnicity *

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

Do you have an official autism diagnosis? *

Yes, receiving/received 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

We require this information for the purposes of the University of Minnesota affiliated evaluation study of AMP.

Do you have a guardian? *

Yes
No

If you have a guardian, please fill out the guardian-related fields below. If you do not have a guardian, please skip to the question "Why do you want to be an AMP mentor?"

Guardian Name

First

Last

Guardian Email

Guardian Phone #

What are your guardian's preferred methods of contact?

Email
Text
Phone call

Why do you want to mentor an autistic teen? *

What strengths/skills/experiences could you offer as a mentor to an autistic teen? Please explain. *

Are you able to commit to meeting with a mentee via Zoom for 1 hour/week during the upcoming school year (not including holiday and break weeks)? *

Yes
No

Please list your availability on weekday afternoons/evenings and weekends for a weekly 90-minute 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, please email us at info@autismmentorshipprogram.org.

By signing my name below, I agree to learn more about 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 and a formal opportunity to consent to my participation in this research prior to participating in AMP. *

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 mentors participate in the study.

By typing my name below, I grant permission for AMP to contact me online to conduct a personal interview for additional screening and for ongoing participation in the mentorship program. *

By typing my name below, I consent to information being anonymously (without names) shared with a prospective mentee(s) to aid in determining a suitable match. Once a mentor/mentee match is determined, my identity and other relevant information (excluding personal contact information) will be shared with the mentee to the extent it aids in facilitating a successful match. *

Where did you hear about AMP?