AMP Mentor Application Form – Autism Mentorship Program

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. This information will only be used to confirm that you live in Minnesota.

City, State, ZIP *

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 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 proof of 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

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.

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 be an AMP mentor? *

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 to 1-1/2 hours/week during the upcoming school year? *

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, you can email megan.perera@autismmentorshipprogram.org.

By signing my name below, I consent to 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 mentors participate in the research study for the 2022-2023 program year.

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 basic 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 will be shared with the mentee to the extent it aids in facilitating a successful match. *

Basic information may include age, gender identity, sexual orientation, race/ethnicity, and personal interests/hobbies.

Where did you hear about AMP?