Nurture® Program Mentor Application
Sign in to Google to save your progress. Learn more
Your Name *
Your Email *
Your Address *
Your Mobile Phone Number *
How did you hear about the Nurture® Program? If referred by a friend or current mentor, please include her name. *
Employment History *
Please list your three most recent employers, dates of employment and reason for leaving.
Do you currently work outside the home? *
Current Position and Employer *
If you work outside the home, please list your current employer (company or organization) and your job title.
Do you speak a language in addition to English? If yes, what language(s) do you speak? *
Volunteer Experience *
If you have volunteered previously, please list those experiences below.
References *
Please list three (3) references. You may include personal, work or volunteer references. Please include each reference's NAME, PHONE NUMBER and EMAIL ADDRESS.
Please tell us about your experience in parenting, including the age(s) of your child(ren) and why you want to share that experience as a Nurture® Program mentor. What do you hope to gain from this experience? *
What, if any, experience do you have outside of parenting that relates to early childhood development, parent support, education, community outreach, counseling, etc? *
Any mom who delivers in one of our partner hospitals has the opportunity to enroll in the Nurture® Program. Therefore, the moms you support will have different backgrounds, histories and levels of need. This may include various family structures, a wide range of income levels, possibly drug/alcohol issues, etc. Are there any scenarios that you would feel highly uncomfortable supporting? Please explain. *
Do you consider yourself to have strong opinions about 'hot button' parenting topics (vaccinations, co-sleeping, breast/bottle feeding, stay-at-home/working, etc.)? If so, do you feel that you would be able to effectively support moms who might not share your views? Please explain. *
Do you have consistent access to a computer/tablet and wifi? *
Does your schedule allow you to commit one to two hours each week to consistently communicate with ten to 15 enrolled moms? *
Do you feel you will be able to consistently reply to texts from moms in a timely manner (within 24 hours)? *
Does your schedule allow you to commit to communicate with your Nurture® Program supervisor on a regular basis? *
Is there anything else related to your application that you would like to share with us?
Are you able to make a one (1) year commitment to mentoring moms of newborns? *
We prefer that, during the important and vulnerable first year, moms enrolled in the Nurture® Program maintain the same mentor. A three (3) year commitment from mentors, the entire duration in which moms are enrolled in the program, is most desired.
All candidates are required to complete new mentor training which is offered on-line and to sign a Nurture® Program mentor pledge. *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of NurturePA Inc.. Report Abuse
Google Forms