Parent Mentor Program – Down Syndrome Association of the Upstate

First Name *

Last Name *

Email Address *

Phone Number *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Current employment *

How many hours per week are you available to volunteer? *

Which outreach programs are you interested in? (Check all that apply) *Parent Mentor Program (new/expectante parents)Bereavement (peer-to-peer support throughout loss)Aging Ally (aging adults)Family Care Fund (medical outreach)

You are a patient person *

You are an organized person *

You are a good negotiator *

You are professional *

You are comfortable with technology *

You are able to see multiple points of view. *

You are an empathetic person *

You are comfortable with public speaking *

You have a positive attitude *

You believe that the value of a human is not dependant on their diagnosis *

Why are you interested in being an Outreach Representative? *

What if your professional/education background? *

Are there any hospitals or medical offices you would prefer to visit? Please state your connection with that provider. *

Please indicate all Medical Outreach volunteer assignments that might interest you: (check all that apply) *New and Expectant Parent Outreach Representative: Hand delivering resources to new families. Meeting with the family to listen, offer support, share stories etc.Database Clerk: Managing the collection of data about office visits, prenatal referrals, birth statistics for the local area and state. 2Resource Organizer: Organizing resource packs for new/expectant parents.Resource Management: Managing the distribution of program materials.Medical Outreach Fundraising Representative: Soliciting donors and fundraising efforts for medical outreach.Gift Basket Organizer: Organizing items for gift baskets/care packages and assembling them.Medical Outreach Presentation Specialist: Participate in parent panels sharing experiences with medical professionals.

What is your preferred language? *

Can you speak any other languages? *

What is your preferred method of communication? *

Can you maintain professionalism in tough situations? *

Can you remain unbiased with new/expectant parents? *

Do you believe you can share your story without emotions? *

Was your diagnosis delivery a pleasant experience or a negative one? Please briefly explain. *

Please define what you believe an Outreach Program is. *

The primary goal of our Outreach Program should be? Please describe what you believe the goals of a sustainable Outreach Program should be. *

What type of advocay programs have you helped with previously? *

Did you feel supported throughout your diagnosis delivery by the local community or local organization? If you did not, what do you wish looking back, could have been different? *

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