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IL NET Peer to Peer Mentoring Application

IL-NET/ APRIL Peer To Peer Mentoring Application

Congratulations! You are ready to set a goal and work towards improving your organization to achieve even better outcomes for people with disabilities/disabled people in your area. Please fill out the application below to the best of your ability. If you have questions, you may contact Mary Willard, Peer Mentor Coordinator for the ILRU training and technical assistance center (Director of Training and Technical Assistance for APRIL) mwillard@april-rural.org or 406.544.1668 at any time. We are so excited that you are ready to take the next step in your IL journey.

The IL-NET is supported by grant numbers 90ILTA0001 and 90ISTA0001 from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.

1. Please indicate below which mentoring program you are applying for: *This question is required.

2. Please fill out the following contact form to the best of your ability.

First Name *This question is required.

Last Name *This question is required.

Title

Organization Name *This question is required.

Street Address

City

State

Email Address *This question is required. This question requires a valid email address.

Phone Number

URL

3. How many staff are in your organization?

	Full time
	Part time

4. Any other information about your organization that might be helpful for a mentor to know?

5. If you are not the Chair or ED of a SILC , please check at least one box below to indicate that a decision maker at your SILC knows about and supports you applying for services. If you can not check at least one box below, please return to fill out an application once support has been secured. Please note that a follow up will be made with your leadership to ensure accuracy.

SILC Chair
SILC Executive Director or Staff Laison

5. If you are not the CEO or Executive Director of your CIL , please check the box below to indicate that the CIL Executive Director or CEO supports you applying for services. If you can not check the box below, please return to fill out an application once support has been secured. Please note that follow up will be made to ensure.

My Executive Director or CEO Support my Application for Services

5. Please indicate below the amount of time you have been in your organization:

	Amount of time in current position:
	Amount of time spent in Independent Living field overall:

6. Please check the areas that best describes the overarching goal you are seeking support for.

Nursing Home Transition
Youth Transition
New Executive Director orientation
New Program Manager/AD orientation
Fund Development/Fee For Service programming
Building Peer Support Program
Outreach to underserved areas/ Rural outreach and Community Development
Board Development
Other - Write In Please enter an 'other' value for this selection.

6. Please use as much space as you need to describe your top specific issues or barriers you’re facing and what outcomes you would like to achieve through this mentoring. Please include as much detail as possible to help us find the right potential match for you. (Why are you applying for mentoring services?)
*This question is required.

7. What steps (if any) have you and others at your organization already done to address the above issues or barriers? (For example, trainings on this topic you have already accessed, if you have used services with Paula McElwee with the IL-NET, if you have already had a mentor, connections with state networks, and other creative solutions you have tried.

8. Can you think of anything else that might be useful for us to know about your request? Such as, do you already have a mentor/organization you are interested in learning from in mind? Do you have preferences of potential mentors you would like to work with such as must be rural or must serve youth.

9. How did you hear about us?