Optimal Fatherhood

Team
Facilitators / Mentors
Participants
Contact Form

Facilitators / Mentors

Thank you for your interest in serving as a Facilitator for the Obria Oregon Optimal Fatherhood Program. Please complete this form as thoroughly as possible. All information provided will be kept strictly confidential and used only for program-related purposes, including background checks if necessary.

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Thank you for your response. ✨

Name(required)

Email(required)

Phone Number(required)

Address

City

State

Zip Code

Date of Birth (YYYY-MM-DD)

Social Security Number (SSN)

*for background check purposes only

What is your ethnicity?

African American Hispanic/Latino White/Caucasian Asian/Pacific Islander Native American Multiracial Other

Highest Level of Education Completed:

High School Diploma Associate's Degree Bachelor's Degree Master's Degree Doctorate's Degree

Current Occupation / Employer:

Have you ever led parenting, mentorship or support groups before?

Yes No

If you answered yes to the question above, please explain:

Do you have any prior criminal convictions?

Yes No

If yes, please briefly explain: A conviction does not automatically disqualify you.

How did you hear about Optimal Fatherhood?

Friend / Family Church Social Media Referral Other

By submitting your information, you are confirming that the information you have provided is true and complete to the best of your knowledge. You also understand that your Social Security Number and personal information will be used solely for background check purposes and will be kept confidential.

Optimal Fatherhood

Free Program for Dads

“I believe that in modern times fatherhood has become a lost art, yet it remains one of the most powerful influences on the future of our families and communities. Every man has the potential to be a great dad,” – Brian Gosser, Chief Program Officer

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