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25
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2
DATA COLLECTION / PROCESSING CONSENT
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Subject to the Data Privacy Act of 2012, all answers to this questionnaire shall be kept confidential and shall be used for invitation of service providers only. No personal information gained from this form shall be processed without your prior consent. Do you consent to register as "life buddy"?
YES
NO
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3
General Information
*
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First Name
Last Name
Age
Please enter your phone
Please Select
Male
Female
Please Select
Please Select
Male
Female
Gender
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4
Address
*
This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Philippines
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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5
Email
*
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example@example.com
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6
Current Work/Business/Course
*
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7
Affiliate / Organization
Mental Health PH
Converge International
Destiny Church
Glorious Hope
Not Alone
Indigitous Philippines
The Lord's Assembly Creekside
Other
Mental Health PH
Converge International
Destiny Church
Glorious Hope
Not Alone
Indigitous Philippines
The Lord's Assembly Creekside
Other
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8
Please specify
Affiliate / Organization
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9
Do you currently serve as a mentor/ coach to others?
*
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YES
NO
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10
How would you rate your mentoring skills on a scale of 1 to 5?
1
2
3
4
5
Subpar
Amazing
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11
Holistic wellness programs that you can facilitate.
*
This field is required.
Choose the top two categories
Emotional Wellness: Self Awareness & Self-Regulation
Mental Wellness: Stress Management, Anxiety, Fears, and Mindfulness
Physical Wellness: Diet and Workout
Spiritual Fitness: Prayer, Quiet or Devotional Time with God, Understanding the Gospel, Divine Principles & Law , Purpose and Calling, World View
Social Wellness: Trust and Connection
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12
Life skill development programs that you can facilitate.
*
This field is required.
Choose the top three categories
Budget Management
Cooking Skills
Clothing Skills
Cleanliness and Hygiene
Organization Skills
Communication Skills
Goal-Setting
Time Management
Decision-making Skills
Other
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13
Please specify
Life skill development programs that you can facilitate
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14
Professional skill development programs that you can facilitate.
*
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Choose the top two categories
Career Education
Communication
Critical thinking and problem solving
Teamwork and collaboration
Positive Attitude
Work Ethic
Leadership
Other
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15
Please specify.
Professional skill development programs that you can facilitate.
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16
Hobbies & Interests
*
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17
Other hobbies and interest not in the list
Hobbies & Interests
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18
Preferred gender you are comfortable to facilitate with
*
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Male
Female
Both Male & Female
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19
Available Day
*
This field is required.
Select as many schedule as you want
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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20
Available Time
*
This field is required.
Select as many schedule as you want
8 A.M. - 11:00 A.M.
11:01 A.M. - 1:00 P.M.
1:01 P.M. - 4:00 P.M.
4:01 P.M. - 7:00 P.M.
7:01 P.M. - 10:00 P.M.
10:01 P.M. onwards
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21
Preferred method of communication with the youth
*
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Virtual
Physical
Hybrid (Virtual & Physical)
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22
Please input your preferred location
Physical & Hybrid
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23
Age bracket you can accommodate
18 - 21 years old
22 - 25 years old
26 - 30 years old
31 - Above
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24
Will you be willing to provide your services to a class or group setup?
*
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YES
NO
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25
Are you also willing to offer your service for free in first 3 to 5 sessions?
*
This field is required.
YES
NO
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26
What is the maximum number of people you can accommodate?
*
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27
Please provide your Facebook link so that we can add you to the facebook community group.
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28
Is your service free of charge?
*
This field is required.
YES
NO
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29
Please provide a monetary value.
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30
Terms and Conditions
*
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31
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Coaching Evaluation
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