Name *

First Name

Last Name

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(###)

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Identify the reasons you are interested in joining this GPS Mentorship Program. Choose one or more of the following:

Being a parent or immediate family member of an individual with special needs who is going through a transitional period in their life.

Demonstrate the ability to effectively and respectfully communicate with a mentor.

Have a desire to build a meaningful relationship with a mentor.

Commit to completing the minimum time with the assigned mentor which is eight hours (flexibility of scheduling is upon mutual agreement between mentor and assignee).

Eight 1-hour sessions

Four 2-hour sessions

Please read and sign below. *

The information I have provided in this application is true and complete to the best of my knowledge. I agree to commit to a minimum of eight hours of mentoring, to be respectful and kind to my mentor, and to receive and ask for support as needed. I give permission for my references to be called and a background check performed if deemed necessary.

First Name

Last Name