Name
*
First Name
Last Name
What would you like to be called?
Pronouns
Email Address
*
Date of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Gender Identity
Race
If under 18, Parent/Guardian Name
First Name
Last Name
If under 18, Parent/Guardian Name Phone
(###)
###
####
If under 18, Parent/Guardian Name Email
What has been the biggest challenge you've had to covercome in the past two years?
3-5 Sentences
What is something you're very proud of?
3-5 Sentences
Why do you want an OTA SUMMIT mentor?
3-5 Sentences
What are some strengths you would bring to our community?
3-5 Sentences
I commit to 100% participation. I commit to being on time to all events and commitments.
*
Yes
I commit to a weekly 3-5 hour time commitment (not including transportation).
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Yes
If I cannot attend an OTA function or a meeting with my mentor, I will give my mentor 24 hours' notice.
*
Yes
I commit to respecting confidentiality.
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Yes
I will not use or have in my possession illegal drugs, alcohol, or tobacco, products at OTA events and functions.
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Yes
I commit to being respectful of others and their possessions.
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Yes
I will not use or have in my possession weapons of any kind at OTA events and functions.
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Yes
I authorize OTA to use my name, likeness, written and/or spoken word, photos, and video footage of me, in any media whether known or unknown in perpetuity, so that I can assist OTA to do work with other young people like me.
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Yes
I give my word to abide by the rules and guidelines of the SUMMIT program. I understand that information from this application may be shared with my mentor. This application was completed by me. I have read all of the information on this application and all of my answers are true to the best of my knowledge.
*
Yes
OTA requires that you certify your application by submitting an electronic signature. To certify your application, provide an electronic signature (type your name) below and click "Submit." I certify that the information I provided is accurate and true to my knowledge.
*
