interested in being connected to a caring adult? The LIFEGUIDES mentoring program is aimed at building life skills and community connections for foster youth ages 17-23 years old. You will be matched with a volunteer LIFEGUIDE based on interests and preferences. You will meet weekly at an agreed upon location for the 12 week program. Name* First Last Independent Living Specialist or Case Manager InformationIndependent Living Specialist or Case Manager Name* First Last Independent Living Specialist or Case Manager Email* Independent Living Specialist or Case Manager Phone*Placement*Foster HomeGroup HomeAge 18+RelativeNon-RelativeOtherIf other, please explain.*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Do you have any children?*YesNoEmail* Date of Birth* Your Gender*FemaleMaleYour Ethnicity*African-AmericanAsian-AmericanCaucasianHispanic-LatinoMulti-EthnicOtherIf other, please specify.*Current Job (if working):Are you currently attending school?*YesNoIf yes, which school and what area of study?*Grade in School*9101112GEDCertificationCollegeOtherIf other, please specify.*Are you currently enrolled in on of the following programs?*PESSExtended Foster Care (EFC)RTIOpted out of careOtherIf other, please explain.*Are you interested in joining the Military?*YesNoIf yes, what branch of the Military are you interested in?*What are your career goals?*Do you volunteer or do charity work? If yes, where at?*What computer skills do you have (please check all that apply)?* Microsoft Word Excel Powerpoint Photoshop Access Garage Band or other recording program Web design Other None If other, what computer skills?What computer skills would you like to learn?*What is the best time to meet with your LIFEGUIDE (please check all that apply)?* Weekday Mornings Weekday Afternoons Weekday Evenings Weekend Mornings Weekend Afternoons Weekend Evenings Most of the time, I feel...* thankful excluded strong happy included weak capable sad confident dumb proud unstable frustrated smart normal excited talented different content angry special respected prepared financially calm valuable hopeful anxious/worried worthless depressed prepared afraid out of control resourceful supported To help us match you with a LIFEGUIDE, we'd like to get to know you.What are your interests?*What is your favorite food?*What is your favorite place to eat?*What is your favorite travel destination and why?*Favorite TV show?*Favorite movie?*Favorite thing to do in your free time?*Favorite book/magazine?*What other languages do you speak?*Have you played sports?*YesNoIf yes, what sport(s)?*Have you played a musical instrument?*YesNoIf yes, what instrument(s)?*Please describe your personality (check all that apply):* quiet talkative outgoing moody cheerful nervous shy friendly analytical visionary artistic nurturing adventurous reserved other If other, please describe:*What personal qualities would you like in a LIFEGUIDE?*What is your primary mode of transportation?*BusCarRide with a friend/relative/otherWhy do you want a LIFEGUIDE?*When working with a LIFEGUIDE, do you have a preference to any of the following? Please keep in mind that we will do our best to match you with a LIFEGUIDE who meets your preferences, but we cannot guarantee an exact match.Gender*It doesn't matterYesIf yes, which gender?*FemaleMaleReligion*It doesn't matterYesIf yes, which religion?*Ethnicity*It doesn't matterYesIf yes, which ethnicity?*African-AmericanAsian-AmericanCaucasianHispanci/LatinoMulti-racialOtherIf other, which ethnicity?*Are there any other preferences you have for a LIFEGUIDE?*CommentsThis field is for validation purposes and should be left unchanged.