Elder Application Question Title * 1. Personal Information Name Address City State -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP Email Address Phone Number Question Title * 2. Tribal Affiliation (type N/A if not applicable) Question Title * 3. Chapter House (if Navajo Nation Tribal Member) Question Title * 4. Age Question Title * 5. Birthdate Question Title * 6. LGBTQIA Identity as a member of the LGBTQ community Does not identify as a member of the LGTBQ community Two-Spirit Unknown Question Title * 7. Gender Male Female Gender Fluid/Does Not Identify as Male or Female Question Title * 8. Ethnicity Hispanic or Latino Non-Hispanic or Non-Latino Question Title * 9. Racial Group Native American or Alaska Native African American/Black White/Caucasian Asian/Asian American Native Hawaiian or Other Pacific Islander Two or More Races Question Title * 10. Are you a U.S. Veteran? Yes No Question Title * 11. Income level $24,999 or less $25,000 to $39,999 $40,000 to $59,999 $60,000 to $74,999 $75,000 to $99,999 $100,000 to 149,999 $150,000 or more Don’t know Question Title * 12. Housing Owned by mortgage or loan Owned by without mortgage or loan Rented Occupied without payment or rent Don’t know Question Title * 13. Availability Mornings Afternoons Evenings Monday Monday Mornings Monday Afternoons Monday Evenings Tuesday Tuesday Mornings Tuesday Afternoons Tuesday Evenings Wednesday Wednesday Mornings Wednesday Afternoons Wednesday Evenings Thursday Thursday Mornings Thursday Afternoons Thursday Evenings Friday Friday Mornings Friday Afternoons Friday Evenings Saturday Saturday Mornings Saturday Afternoons Saturday Evenings Sunday Sunday Mornings Sunday Afternoons Sunday Evenings Question Title * 14. How many mentorship hours are you able to accommodate per month? Question Title * 15. Why do you wish to be an Elder mentor? Question Title * 16. Do you have past experience working with youth? Yes No Question Title * 17. If yes, what was your role/experience? Question Title * 18. How would you rate your technology abilities? Little to no knowledge 2 3 4 Expert Question Title * 19. Do you have reliable transportation? Yes No Question Title * 20. If not, do you utilize public transportation? Yes No Question Title * 21. Describe any skills, education, accomplishments, spiritual knowledge/language that you possess Question Title * 22. Are there any health issues, mobility issues, and/or accommodations that Phoenix Indian Center staff need to be aware of? Question Title * 23. Are you willing to complete a fingerprint clearance and background check? Yes No Question Title * 24. How did you hear about this opportunity? Twitter Facebook Instagram Phoenix Indian Center website Family/Friends Flyers Other (please explain) Question Title * 25. Do you prefer to do your interview via Zoom or In-Person at the Phoenix Indian Center. Zoom In Person Question Title * 26. I understand that as an Elder mentor, I will need to complete required background checks and fingerprint clearance Yes No Question Title * 27. I understand that as an Elder Mentor, I will need to attend an orientation Yes No Question Title * 28. I certify that the information completed in this application is correct to the best of my knowledge Yes No Question Title * 29. Print Name Question Title * 30. Today's Date Date / Time Date Done
