Name
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First Name
Last Name
Email Address
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Phone Number
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(###)
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City and State
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Gender Expression
Date of Birth
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Education, including degree(s) and year(s)
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For example: Bachelors Degree from Rice University, 20XX
Work history, including year(s)
Emergency Contact
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First Name
Last Name
Relationship to Emergency Contact
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Emergency Contact Phone
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(###)
###
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Emergency Contact Email
What is your visual acuity? How long have you been blind or visually impaired?
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Do you have experience with a PC, a Mac, or other adaptive technology equipment?
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How long have you been using iOS devices?
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What iOS or other Apple devices do you own?
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Do you have access to a stable Wi-Fi connection?
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Do you have access to an alternative method of communication?
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For example, do you have a landline, access to another cell phone, a computer or iPad with Zoom or Skype, or a smart speaker? Please explain.
What is your Apple ID?
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Which of the following objectives can you perform using VoiceOver, not the built-in assistant Siri?
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Check all that apply
Which of the following objectives would you like to learn to perform using VoiceOver, not the built-in assistant Siri?
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Check all that apply
Are you a registered member of iBUG?
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For example, are you on our mailing list?
How did you hear about iBUG?
How much time do you have available per week to participate as a mentee?
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When could you meet with your mentor?
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Check all that apply
Please acknowledge the following statements to indicate that you have read and understood them.
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a. The iBUG Jumpstart Mentoring Program provides basic training on iOS devices, applications, gestures, and features.
b. The iBUG Jumpstart Mentoring Program provides training on the use of VoiceOver exclusively.
c. I will be expected to turn on the screen curtain and use VoiceOver exclusively.
d. I must complete all homework assignments and recommended reading as stated by my mentor.
e. Failing to complete my homework, complete the reading assignment, or practice the gestures will result in removal from the iBUG Jumpstart Mentoring Program.
f. Canceling or rescheduling on two or more occasions without just cause may result in removal from the iBUG Jumpstart Mentoring Program.
g. I will be expected to participate in the iBUG Buzz Conference held on the Zoom platform on Monday nights from 7:00 to 9:00 PM (Central Time) by calling in or listening to the recordings.
h. iBUG is committed to providing instruction on the objectives identified above exclusively.
i. I will not be instructed on other built-in or third-party applications not identified above.
j. The iBUG JumpStart Mentoring Program consists of twelve two-hour training sessions. Furthermore, my mentor 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 months from the start of the mentoring program.
k. My mentor will determine when I am ready to move on to the next task/objective.
l. I agree to be tested to prove that I have learned a task/objective.
m. The iBUG JumpStart Mentoring Program will last until I have learned all twelve tasks/objectives or twelve sessions, whichever occurs first.
n. It is my responsibility to work diligently to learn all twelve tasks/objectives, and even if I do not complete them all for any reason, there will be no extension of the twelve-session program.
o. It is my responsibility to advise my mentor if I upgrade my iPhone. Furthermore, I understand that it may be necessary to reassign me to a different mentor.
p. iBUG Today reserves the right to reassign me to a different mentor.
q. After I complete the iBUG JumpStart Mentoring Program, I cannot contact my mentor for ongoing help, and I must participate in the iBUG Buzz Conference on Monday nights to obtain help.
r. Absent good cause, I am not eligible to participate in the iBUG JumpStart Mentoring Program if I previously participated in the iBUG JumpStart Mentoring Program.
s. I am proficient in the English language to participate in the iBUG JumpStart Mentoring Program.
t. Due to limited resources, iBUG may not be able to provide training to individuals who have severe neurological, cognitive, or physical limitations that prevent them from navigating and performing VoiceOver gestures.
I have read and accept all the provisions of the foregoing iBUG JumpStart Mentoring Program Waiver Form.
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I verify all of the above information is correct and true to the best of my knowledge.
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Type your full name to represent your signature on this application form.
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Date of Execution
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