Partners™ for Youth with Disabilities

Mentoring programs that assist young people to reach their full potential





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Adult Application

This application is for adults interested in becoming mentors and Peer Leaders.

You have two options for completing this application:

Apply online below and submit answers through this website
Or, download application (.pdf file), print, complete and mail to the address included.

It is estimated that this application may take 10-30 minutes to complete. Please, review the entire page before you start. Need help? Email: info@pyd.org

Applied Previously?
If you have applied previously to PYD in the last six months you do not have to apply again. Simply, complete the short program reapply page.

Required information is indicated with an *asterisk.

Start by Choosing the Programs You Are Interested In (ALT+S):
*Select a program (choose ALL that apply):		Program Options: Mentor Match Partners Online Peer Leadership Young Entrepreneurs Project Not sure which program to choose
Personal and Contact Information (ALT+P):
*Last name:
*First name:
*Home phone:
Work phone:		Extension:
Cell phone/pager:
Email address:
*Street address (include floor and apartment #):
*City:
*State:
*Zip code:
*Race/ethnicity (Check ONE only):		Race: American Indian/Alaska Native Asian Black/African-American Hispanic/Latino Native Hawaiian/Pacific Islander White/Caucasian Other Other

*Marital status (Check ONE only):		Marriage Option: Married, spouse present Married, spouse absent Unmarried, living with partner Widowed Divorced Never married Other: Other

*Date of birth (mm/dd/yy):		*Age:
*Primary language spoken at home:
*Gender:		Male Female
*Have you had prior experience as a parent or guardian?		Yes No
*Have you had prior experience as a mentor?		Yes No
Education/Employment Experience (ALT+E):
*What is your highest level of education completed? (Check ONE only)		Education High school diploma College courses Associate's degree BA/BS degree Master's degree Doctoral degree Other: If other describe

*What is your employment status? (Check ONE only)		Employment Status Unemployed Employed Retired Student Other If other describe

If not a student, which of the following best characterizes current or immediate past employment?		Past Employment Managerial/professional Technical/sales/administrative Service Military Law enforcement/justice Religious Other: If other describe
General History (ALT+G):
*Current employer or school:
*Length of employment:
*Do you speak any foreign languages?
*Do you have any special skills?:
*Do you have a driver's license?:		Yes No
License #:
*Access to a car?
Auto insurance company?
Family/Household Members (ALT+F):
Family/household member 1:		Family/household member 1 Name: Age: Gender: Male Female Type of job/school: Relationship:

Family/household member 2:		Family/household member 2 Name: Age: Gender: Male Female Type of job/school: Relationship:

Family/household member 3:		Family/household member 3 Name: Age: Gender: Male Female Type of job/school: Relationship:

Family/household member 4:		Family/household member 4 Name: Age: Gender: Male Female Type of job/school: Relationship:

List additional household members:
Background, Interests and Match Preferences (ALT+B):
*Describe the family in which you grew up (how many parents, siblings, family relationships and values).


*How do you spend your leisure time (hobbies, interests, etc.)?


*History of community involvement and experience with youth programs:


*Describe what kind of boy/girl would make the best match with you (age group, disability, background, challenges, interests, career goals, personality type, etc.).


*How far are you willing to travel (time and/or specific areas)?


*Why do you want to become a mentor for Partners for Youth with Disabilities?


Additional comments, information, questions:


*Have you ever been convicted of any offense by civilian or military court? Yes No

*Have you been or are you now being charged with any criminal offense, or are any civil court actions or judgments now pending against you? Yes No

If you answered 'yes' to either of the above, please provide details in the following text field. State the date and place of each arrest, court action or judgment. Give the nature of the charge or court actions, and current status of disposition including any sentence or fine imposed. Provide a complete explanation of the circumstances.


*Have you ever been treated for alcohol or drug dependency? Yes No

If yes, please list date(s) and place(s) of treatment:

Do You Feel That You Can Meet the Minimum Standard of (ALT+M):
For Partners Online:		Partners Online A) Email contact with a mentee twice per week? Yes No B) Chat or Instant Message contact with a mentee once a week? Yes No C) In person contact with a mentee at least 3 hours once every 3 months? Yes No D) Do you sincerely feel that you will be able to remain in the program for at least one year? Yes No

For all other programs (MM/PL/YEP):		Other Programs A) Telephone or email contact with a mentee once a week? Yes No B) In-person contact with a mentee at least once every month? Yes No C) Do you sincerely feel that you will be able to remain in the program for at least one year? Yes No
Personal References (ALT+R):
Please list three (3) people who know of you and your interest in becoming a mentor whom we may contact by phone as references. Please include, if possible: Current or most recent job supervisor and An individual who is not a close friend or relative

*Personal reference 1:		Reference 1 Name: How long known to you?: Work phone: Home/cell phone:

*Personal reference 2:		Reference 2 Name: How long known to you?: Work phone: Home/cell phone:

*Personal reference 3:		Reference 3 Name: How long known to you?: Work phone: Home/cell phone:
Nature of Disability (ALT+D):
*What is the nature of your disability? (check ALL that apply):		Nature of disability None Physical Blind/low vision Deaf/hard of hearing Deaf-blind Learning Cognitive Emotional Other Other

If you checked more than one box above, what is your primary disability?


If applicable, describe your functional abilities and limitations. What accommodations are needed?

PYD Program History (ALT+H):
List all PYD programs you have participated in:		PYD participation Program 1: Program 1 start date (mm/yy): Program 2: Program 2 start date (mm/yy): Program 3: Program 3 start date (mm/yy):

How many (if any) mentees have you been matched with and how long did each match last?
Primary Interest in Becoming a Mentor (ALT+I):
*What is your primary reason for applying to be a mentor? (Check ONE only)		Primary reason To give back to the community To support a child with a disability Had a positive experience with a mentor as a child PYD sponsored community service project Experience for career/educational development Other: Other:
Final Acceptance of Terms (ALT+Z):
*Who completed this application?		Yes, the applicant completed this form. No, someone other then the applicant completed this form.

If no, provide name:

*Electronic Approval		Yes, I certify that all the statements made in this application are true, correct and complete to the best of my knowledge and are made in good faith. I understand that any misinformation may be cause for disqualification or termination.

Review the entire form and confirm that all of your answers are correct. Print and file a copy of this application with your personal records.

Adult Application

Start by Choosing the Programs You Are Interested In (ALT+S):

*Select a program (choose ALL that apply):

Personal and Contact Information (ALT+P):

*Last name:

*First name:

*Home phone:

Work phone:

Cell phone/pager:

Email address:

*Street address (include floor and apartment #):

*City:

*State:

*Zip code:

*Race/ethnicity (Check ONE only):

*Marital status (Check ONE only):

*Date of birth (mm/dd/yy):

*Primary language spoken at home:

*Gender:

*Have you had prior experience as a parent or guardian?

*Have you had prior experience as a mentor?

Education/Employment Experience (ALT+E):

*What is your highest level of education completed? (Check ONE only)

*What is your employment status? (Check ONE only)

If not a student, which of the following best characterizes current or immediate past employment?

General History (ALT+G):

*Current employer or school:

*Length of employment:

*Do you speak any foreign languages?

*Do you have any special skills?:

*Do you have a driver's license?:

License #:

*Access to a car?

Auto insurance company?

Family/Household Members (ALT+F):

Family/household member 1:

Family/household member 2:

Family/household member 3:

Family/household member 4:

List additional household members:

Background, Interests and Match Preferences (ALT+B):

*Describe the family in which you grew up (how many parents, siblings, family relationships and values).

*How do you spend your leisure time (hobbies, interests, etc.)?

*History of community involvement and experience with youth programs:

*Describe what kind of boy/girl would make the best match with you (age group, disability, background, challenges, interests, career goals, personality type, etc.).

*How far are you willing to travel (time and/or specific areas)?

*Why do you want to become a mentor for Partners for Youth with Disabilities?

Additional comments, information, questions:

*Have you ever been convicted of any offense by civilian or military court?

*Have you been or are you now being charged with any criminal offense, or are any civil court actions or judgments now pending against you?

*Have you ever been treated for alcohol or drug dependency?

If yes, please list date(s) and place(s) of treatment:

Do You Feel That You Can Meet the Minimum Standard of (ALT+M):

For Partners Online:

A) Email contact with a mentee twice per week?

B) Chat or Instant Message contact with a mentee once a week?

C) In person contact with a mentee at least 3 hours once every 3 months?

D) Do you sincerely feel that you will be able to remain in the program for at least one year?

For all other programs (MM/PL/YEP):

A) Telephone or email contact with a mentee once a week?

B) In-person contact with a mentee at least once every month?

C) Do you sincerely feel that you will be able to remain in the program for at least one year?

Personal References (ALT+R):

Please list three (3) people who know of you and your interest in becoming a mentor whom we may contact by phone as references. Please include, if possible:

*Personal reference 1:

*Personal reference 2:

*Personal reference 3:

Nature of Disability (ALT+D):

*What is the nature of your disability? (check ALL that apply):

If you checked more than one box above, what is your primary disability?

If applicable, describe your functional abilities and limitations. What accommodations are needed?

PYD Program History (ALT+H):

List all PYD programs you have participated in:

How many (if any) mentees have you been matched with and how long did each match last?

Primary Interest in Becoming a Mentor (ALT+I):

*What is your primary reason for applying to be a mentor? (Check ONE only)

Final Acceptance of Terms (ALT+Z):

*Who completed this application?

If no, provide name:

*Electronic Approval