Youth in Action - YA! Coach Application
Thank you for your desire to invest in Latino youth!
The questions below will help us to get to know you and match you with a student.
Contact Information
First name:
*
Last name:
*
Preferred Name:
Street 1:
*
Street 2:
City:
*
State:
Choose
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
Other
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
*
Zip:
*
Cell phone:
*
Other phone:
Email address:
*
Emergency Contact
In the event of an emergency, whom should we notify?
First name:
*
Last name:
*
Cell phone:
*
Relationship:
Choose
Child
Co-worker
Friend
Other
Parent
Partner
Sibling
Significant Other
Spouse
Supervisor
Demographics
Please help us get a better idea of the make-up of our volunteers by completing this demographic section. If you are not currently employed, please write "not working."
Date of birth:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
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Year
2022
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2012
2011
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1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
*
Race or Ethnicity:
Gender or Gender Identity:
*
Employer:
*
Education
Are you a student?:
Choose
No
Yes
*
Highest Education Level:
Choose
Associate degree
Bachelors degree
Doctoral degree
High school or Equivalent
Less than High School
Masters degree
Some college
Some High School
Trade/Vocational school
*
If Current Student, School Name:
What is/was your major/degree?:
*
Languages
*
Spanish Skills:
0 - None
1 - Beginning
2 - Intermediate
3 - Advanced
4 - Fluent
What YA! Program site do you prefer?
Please let us know if you would prefer to be a Coach for YA! Minneapolis or YA! St. Paul. We will do our best to place you at your preferred site.
*
YA! Site Preference:
YA! Minneapolis
YA! St. Paul
Tell us about yourself
Why do you want to become a Coach?
Experience
Please tell us about your qualities, skills, training, experience, or other attributes that may benefit a youth.
Health History
Do you have any health-related concerns which could affect your ability to perform the activities expected of you as a Coach, or ensure the safety of the student in your care, especially in the event of an emergency? If so, please explain.
Background Information
Have you ever been...
Denied participation in a youth program:
Choose
No
Yes
*
Investigated for neglect or abuse:
Choose
No
Yes
*
Arrested or convicted of a crime:
Choose
No
Yes
*
If you answered 'yes' to either question above, please explain.
Personal Reference
Please provide us with a personal reference that is not a family member, and can speak to your character.
First name:
*
Last name:
*
Cell phone:
*
Email address:
*
Relationship:
Choose
Child
Co-worker
Friend
Other
Parent
Partner
Sibling
Significant Other
Spouse
Supervisor
*
I Agree
By submitting this form, I attest that the information I have provided on the form is true and accurate.
I agree/understand that: (1) this information may be shared among CLUES staff in order to accommodate my volunteer service with the organization; (2) submitting this application form does not automatically register me as a CLUES volunteer; (3) some volunteer/intern positions may have background check requirements; (4) and there may be certain qualifications I must meet, including the acceptance of established volunteer policies and procedures, before I may begin volunteering.
My consent begins on the date I sign this form and lasts for the duration of the time I am volunteering at CLUES.
I Agree
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