Nurture® Program Mentor Application

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

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 their name. *

Employment History *

Please list your three most recent employers, dates of employment, and reason for leaving.

Do you currently work outside the home? *

Yes

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? *

What is your ethnicity?

Hispanic or Latino

Not Hispanic or Latino

Clear selection

Which racial category best describes you?

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Multiracial

Prefer not to answer

Other:

Clear selection

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? *

Do you have any specific pregnancy or parenting experiences that might make you particularly well suited to support other moms with similar experiences? If you are comfortable sharing, please check any that apply.

Postpartum depression or anxiety

Traumatic birth

Twins

Infertility

Pregnancy loss

Infant loss

Feeding challenges

NICU stay

Single parenting

Other:

Any mom can enroll in the Nurture® Program and we support moms from all walks of life. 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? *

Yes

Does your schedule allow you to commit one to two hours each week to consistently communicate with 10-15 enrolled moms? *

Yes

Do you feel you will be able to consistently reply to texts from moms in a timely manner (within 24 hours)? *

Yes

Does your schedule allow you to commit to communicating with your Nurture® Program team leader on a regular basis? *

Yes

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.

Yes

I'm not sure

All candidates are required to complete new mentor training, which is offered online, and to sign a Nurture® Program mentor pledge. *

I agree to complete the online training.

I agree to sign the Nurture® Program mentor pledge.

Required

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of NurturePA Inc..

Does this form look suspicious? Report

Forms