JumpStart Mentor Application Name * First Name Last Name Email Address * Phone Number * City and State * Gender Birth Date * MM DD YYYY Education, including degree(s) and year(s): * Work history, including year(s): Emergency Contact (Name, Relationship, Phone, E-mail): * What is your visual acuity? How long have you been blind or visually impaired? * Do you have experience with a personal computer, Mac, or other adaptive equipment? If so, explain: How long have you been using iOS devices? What iOS or Apple devices do you own or have access to in your home? Do you have a stable Wi-Fi connection? Yes No Sometimes Do you have an alternative method of communication? For example, do you have a land line, access to another cell phone, a computer with Zoom or Skype, or a smart speaker? Do you have an Apple ID? Yes No Which of the following twelve tasks/objectives can you perform? Use VoiceOver gestures Answer and disconnect phone calls Use the iPhone virtual keyboard or a Bluetooth keyboard. Use Siri and dictation Create a contact Purchase and download an application from the App Store Send and receive text messages Send and receive e-mail messages Use a podcast app Use the Zoom app to connect to the iBUG Buzz Conference Use FaceTime Surf the internet with Safari What apps (top 10) do you use on a regular basis? What apps do you recommend for a new user? Are you a registered member of iBUG (i.e., on the iBUG mailing list)? Yes No How much time do you have available per week to participate as a mentor? When could you meet with your mentee? Check all that apply. During the day During the evening Monday Tuesday Wednesday Thursday Friday Saturday Sunday Please check off the following statements to indicate that you have read and understood these statements. * I understand that prior to being accepted as a mentor in the iBUG JumpStart Mentoring Program, I will be expected to participate on the iBUG Buzz Conference held on the Zoom platform on Monday nights from 7:00 to 9:00 PM (Central Time) for a period of two months. During that time, I understand that I must participate fully in the call by answering and making comments on questions posed by callers. iBUG may determine that the two-month period can be shortened based on my prior work history, experience doing demonstrations at iBUG training sessions, or participation in other assistive technology programs. I understand that the iBUG Jumpstart Mentoring Program provides basic training on iOS devices, applications, gestures, and features. I understand that the iBUG Jumpstart Mentoring Program provides training on the use of VoiceOver exclusively. I understand that I will be expected to instruct my mentee to turn on the screen curtain and use VoiceOver exclusively. I understand that I must give clear homework assignments and recommended reading assignments, and assess whether they were completed. I understand that failing to complete the status report for my mentee on a regular basis will result in removal from the iBUG Jumpstart Mentoring Program. I understand that cancelling or rescheduling on two or more occasions without just cause may result in removal from the iBUG Jumpstart Mentoring Program. I understand that I will be expected to attend and participate in the quarterly and special iBUG Jumpstart Mentoring Program meetings. I understand that iBUG is committed to providing instruction on the twelve tasks/objectives identified above exclusively. I understand that I will not be providing instruction on other built-in or third-party applications not identified in the twelve task/objectives above. I understand that the iBUG JumpStart Mentoring Program consists of twelve two-hour training sessions. Furthermore, my mentee and I will decide if we have a single two-hour session or two one-hour sessions per week. All training sessions must be completed within 3 to 4 month from the start of the mentoring program. I understand it is my responsibility to advise the iBUG JumpStart Coordinator if my mentee or I need to temporarily stop mentoring sessions due to illness or other unforeseen circumstances. I understand that I will determine when my mentee is ready to move on to the next objective. I agree to test my mentee to prove that he/she has learned an objective. I understand that the iBUG JumpStart Mentoring Program will last until the mentee has learned all twelve tasks/objectives or twelve sessions, whichever occurs first. I understand that it is my mentee’s responsibility to work diligently to learn all twelve tasks/objectives, and even if he/she does not complete them all for any reason, there will be no extension of the twelve-session program. I understand that it is my mentee's responsibility to advise me if he/she upgrade their iPhone. Furthermore, I understand that it may be necessary to reassign my mentee to a different mentor. I understand that iBUG Today reserves the right to alter, reassign, or remove my mentee assignment. I understand that after my mentee completes the iBUG JumpStart Mentoring Program, he/she cannot contact me for ongoing help, and that they will participate in the iBUG Buzz Conference on Monday nights to obtain help. iBUG JUMPSTART MENTORING PROGRAM WAIVER FORM: In return for the opportunity to provide/receive iOS device training as a Mentor/Mentee with the iBlind Users Group (“iBUG”) JumpStart Mentoring program, I hereby forever release, acquit and discharge iBUG Today and its officers, directors, trustees, agents, employees, representatives, affiliates, successors and assigns (collectively the Released Parties) from any and all claims, demands and causes of action of any and every kind or nature, including those caused in whole or in part by the negligence of any of the Released Parties, which I may now or in the future have against any or all of the Released Parties and that arise in whole or in part as a result of my involvement with iBUG Today and the iBUG JumpStart Mentoring Program. I also understand and agree that iBUG Today assumes no liability for accidents or acts of negligence or gross negligence by anyone, including Released Parties. I EXPRESSLY AGREE AND ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS AGREEMENT, ITS CONTENTS, UNDERSTAND IT AND VOLUNTARILY SIGN IT. I further agree that no oral representation, statements or inducements apart from the foregoing written agreement have been made. I affirm that all the information contained in this application is true and correct and that there are no material omissions of fact concerning the information herein. If any provision of this Statement is determined to be unenforceable, all other provisions shall remain in full force and effect. I understand that I cannot serve as a Mentor/Mentee until this Statement has been signed. This agreement constitutes the entire agreement with iBUG Today with reference to the subject matter in this agreement, and I do not rely upon any promises, inducements, or arrangements not in this agreement, including but not limited to any oral statements made to me by iBUG Today. This agreement may be amended or modified only in writing, signed by both parties. This agreement shall be governed in all respects, and performance under this agreement shall be judged, by the laws of Texas. Check the box below to indicate that you have read and accept this Waiver form. * I have read and accept all of the provisions of the foregoing iBUG JumpStart Mentoring Program Waiver Form. I verify all of the above information is correct and true to the best of my knowledge. * Agree Type your full name to represent your signature on this application form. * Date of Execution * MM DD YYYY Thank you for applying as a mentor to the iBUG JumpStart Mentoring Program.
