Role Model Program Interest Form

Interested in Being a Role Model?

A free program for families of children who are deaf or hard of hearing, ages birth to 5, to give families the opportunity to meet deaf or hard of hearing adults who have different experiences and varying educational backgrounds. Role Models are trained in various approaches to accommodate families' needs with their child's communication and language development opportunities based on their language model. Role Models meet with each family on a regular basis either at the family home, or remotely, to provide families with a positive and hopeful perspective from their own day-to-day, real life experiences as a deaf or hard of hearing person living in a hearing world.

Commitments/Relationships
How open are you to sharing your personal experiences and learning about the differences in values of your assigned families?*
This program requires a one-year commitment. Can you make a one-year commitment to this program?*

YesNo
Sometimes we may ask Role Models to match with several families. How many total number of families would you be available for to commit to weekly visits with? (both face-to-face and remote). Please provide more information if needed under 'Other'.*

1234 or more

Please tell us the days and times that you would be available to work with families (check all that apply)*

Past Experiences
How many years of experience do you have in work related to being a Role Model? (If none, please enter 0)*
How many years of experience do you have working with families, infants, and young children (birth through 5 years)? (If none, please enter 0)*
What is a recent example of something you successfully achieved as an adult who is deaf or hard of hearing?*

Personal Biography
Please provide a brief biography in your own words describing yourself and your background. *

References
Please provide at least two professional references
Reference 1 (required)*

ProfessionalPersonal
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
What is your relationship with this reference?*
Reference 2 (required)*

ProfessionalPersonal
Name*

First NameLast Name
Email*
example@example.com
Thank you for your interest in becoming a Role Model. After a review of your submitted form, we will contact you soon with more information.
Phone Number*

Area CodePhone Number
What is your relationship with this reference?*
Reference 3 (optional)

ProfessionalPersonal
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
What is your relationship with this reference?

Additional Information and Comments
Would you also be interested in becoming a Mentor? Mentors have a year long commitment teaching ASL, Deaf culture and introducing family to Deaf community.*

YesNo
If accepted, you will be required to pass a background check including fingerprinting. Do you foresee any potential problems with this process?

YesNo
If you have further information or anything you'd like to add that was not previously asked, please share below:
Please list any questions or comments you may have. We will respond via email.
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Interested in Being a Role Model?