Life Coach Young Adult Self-Referral Date of Request(Required) MM slash DD slash YYYY Name(Required) First Last DOB(Required) MM slash DD slash YYYY Current Age(Required)Please enter a number from 12 to 55.Gender at Birth(Required)MaleFemaleRace(Required)WhiteBlack / African AmericanMultiple RaceOtherCurrent Living Situation(Required)IndependentAdoptive HomeRelative / Kinship HomeOtherPhone Number(Required)Email(Required) Address of Current Living Situation(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country County of Current Living Situation(Required)How would you describe your personality?(Required)Please list any notable concerns, behaviors, family or historical information that would be helpful for OCA to be aware of while facilitating this match.(Required)Please list any known triggers.(Required)Please include any other information you feel would aid us in making a match.(Required)Name of DCBS Worker (if applicable) First Last Email of DCBS Worker (if applicable) Name of Case Manager (if applicable) First Last Email of Case Manager (if applicable) Phone Number of Case Manager (if applicable)Name of Therapist (if applicable) First Last Email of Therapist (if applicable)Phone Number Therapist (if applicable)Life Coach Mentor Program Electronic Authorization to ParticipateConsent(Required) I have read and agree with the Life Coach Mentor Program Authorization to ParticipateOrphan Care Alliance, Life Coaching Program appreciates your interest in said applicant participating in our mentor program. As parent/legal guardian of the above-named youth, this form is intended as a means of informing and gaining your consent for your child/young person to participate in the OCA Life Coaching Mentor Program By signing below, I give permission to be involved in OCA’s Mentoring Program. I understand that my child/client will be participating in life skill trainings, education, recreation, social and mentor/mentee activities and outings. I understand that my child/client will be spending time with their matched mentor and approve this ongoing “visitation” with their mentor. (OCA screens all mentors through, interviews, references, background checks, and training.) I also understand that if my child/client does not follow program guidelines that it may jeopardize their participation in the program and may result in termination of the mentoring relationship. I hereby acknowledge that my child/client will be transported by his/her mentor and/or mentor staff while participating in the Life Coaching Program, and that such transportation is voluntary and at his/her own risk. I release Orphan Care Alliance and its staff and volunteers of all liability of injury, death, or other damages that may result from participation in the program, including but not limited to transportation, and hold harmless any Orphan Care Alliance mentor, program staff, or other representatives, both collectively or individually, of any injury, physical or emotional, other than where gross negligence has been determined. Electronic Signature(Required) First Last Date(Required) MM slash DD slash YYYY
