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Required format:

92WRkt4tny6ZeIxVqIuSfrHSaWvuTjyczIZRNVvtWBDr6JdpfhtSqQvrGPbGfawg7T4YH9s244dfBnuKqAJfMdM8PhieheTZiwtWheIB8

HomeGrown Life Coach (HgLC) Application

Welcome to HomeGrown StL and thank you for taking this opportunity to make St. Louis the #1 place for Black youth to heal, grow, and thrive! Through your engagement with a HomeGrown StL you will be providing personalized care to youth and their families to connect them with resources to achieve their goals.

Thank you for your support as we work together to build a better and brighter future for Black Youth in the St. Louis region.

How did you hear about the HgLC study?

* must provide value

Please type your first name

* must provide value

Please type your last name

* must provide value

Proof of Age (i.e., Driver's License, Birth Certificate, Passport)

* must provide value

Upload file

What is your street address?

* must provide value

Please type your city

* must provide value

Please type your zipcode

* must provide value

What is your cell phone number?

* must provide value

What is your alternative phone number?

What is your email?

* must provide value

What are your social media handles for Instagram, Twitter, and/or Facebook?

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How do you describe your ethnicity?

Black or African American

Latino/Latina

White/Caucasian

Pacific Islander

Middle Eastern

American Indian/Native American

Asian

Inter-racial/bi-racial/mixed

Other

Prefer not to say

How do you describe your ethnicity?

What is the highest level of education that you have completed?

* must provide value

High School Diploma/GED

4-year Bachelor's Degree

Apprenticeship/Vocational School

2-year Associates Degree

Master's Degree/PhD

Other

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Please specify other education

* must provide value

Please submit a copy of a transcript documenting your highest completed degree.

Please do not send transcripts of partially completed degrees. You do NOT have to send an official transcript. A
legible copy is sufficient. If you do not have a copy of your transcript, a copy of your diploma can be submitted.

Upload file

What is your most recent post-secondary school of attendance?

What is the name of the program you completed?

What is the date of completion?

Y-M-D

Are you currently employed?

* must provide value

Yes

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What is the name of the company you work with?

* must provide value

What is the name of the previous company you worked with?

What is the phone number of the company you work with?

What is the phone number of the previous company you worked with?

What is your job title?

* must provide value

What was your previous job title?

Please provide the name of your supervisor (if any)

Please provide the name of your previous supervisor

How many hours are you currently working every week?

* must provide value

10 to 20 hours

20 to 30 hours

30 plus hours

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How many hours are you are you available to work as a HomeGrown Life Coach every week?

* must provide value

10 to 20 hours

20 to 30 hours

30 plus hours

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Are there any specific days during the week that you are not able to meet with dyads? (Please select all that apply.)

* must provide value

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

How many years of experience do you have volunteering or working with Black youth ages 12 to 17 and their families?

* must provide value

Less than 1 year

1 to 3 years

3 to 6 years

6 plus years

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How many years of experience do you have volunteering or working with Black youth and their families?

* must provide value

Less than 1 year

1 to 3 years

3 to 6 years

6 plus years

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How many years of experience do you have volunteering, working within, or navigating Missouri's Behavioral Health care systems?

* must provide value

Less than 1 year

1 to 3 years

3 to 6 years

6 plus years

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In the country if Black people do not get a good education or job, it is because

* must provide value

they don't have the same chances as Whites in this country

they have no one to blame but themselves

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What prompted you to apply today? Briefly describe your interest in this program and what you hope to give and receive from participating.

* must provide value

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Please share any challenges and successes that you experienced in your role as a provider, parent, or family member of a child with social, emotional, and/or behavioral challenges. Please respond in 2-5 complete sentences.

* must provide value

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Please list any professional trainings or certifications that you have that you feel would help you support youth and their caregivers (parent, grandparent, aunt/uncle, foster parent).

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Please upload your resume

Be sure to send your most up-to-date resume and that the overall resume highlights your relevant skills and experiences. If you have never prepared a resume, there are sample forms and templates that can be found online.

* must provide value

Upload file

Please upload your cover letter.

Upload file

Confidentiality and Sharing of Information

HomeGrown StL maintains strict privacy and confidentiality policies to ensure the personal privacy of all applicants. Unless you provide us with written permission to share your application with others, the only individuals who can view your application are:

Government representatives to complete federal or state responsibilities
National Institute of Health
University representatives to complete University responsibilities
Washington University's Institutional Review Board (a committee that oversees the conduct of research involving human participants) and Human Research Protection Office. The Institutional Review Board has reviewed and approved this study.

Please be informed that any report or article that we write will not include information that can directly identify you. The journals that publish these reports or articles require that we share your information that was collected for this study with others to make sure the results of this study are correct and help develop new ideas for research. Your information will be shared in a way that cannot directly identify you.

Signature and Verification of Information

Applicants are expected to provide complete, truthful information. Any application found to contain
fraudulent information will not be considered. By typing my signature below, I am agreeing to the following:

I understand that, in order to evaluate my application, HomeGrown StL will verify the information that I have provided including my education, employment, and references.
I agree to cooperate in such review and allow others to provide information regarding my abilities and education.
I hereby solemnly declare and affirm that the facts and matters contained in the foregoing application are true and correct.

Please type your name into the box provided to sign

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Add signature

Please enter today's date

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M-D-Y

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