Mentor Application FormMeet Avery - Lymphoma warrior Online Mentor Application Mentoring is when an experienced person (mentor) who is a knowledgeable and experienced guide, a trusted ally, and caring role model to another (mentee). Step 1 of 3 - Personal Info 33% Mentoring is when an experienced person (mentor) who is a knowledgeable and experienced guide, a trusted ally, and caring role model to another (mentee). Goals: Through this interaction the mentee will develop specific skills and knowledge that will enhance both the mentor and mentee’s personal growth. Personal InformationName* First Middle Initial Last Gender* M F Preferred Phone*Alternate Phone (if available)Preferred Email* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* MM slash DD slash YYYY Year in College* Ethnicity* African American Asian White Hispanic/Latino Other Ethnicity (if other, list below) Diagnosis* Year of Diagnosis* Availability (check all that apply)* Weekdays Weekends Mornings Evenings About YouWhy do you want to be a mentor?*Describe your cancer experience and how this would help you support a younger survivor.*What strengths do you feel you bring to the mentorship role?*You have been assigned to a mentee and have agreed upon a day and time to connect each week. However, every time you call, your mentee seems distracted and uninterested in talking. How would you handle this situation?*Do you understand this is a weekly commitment?* Yes No How do you think you would choose to connect with the survivor you are mentoring?* Email Phone Skype FaceTime What are your interests or hobbies?* Mentor AgreementMentors are childhood cancer survivors who offer their support and time to encourage and cheer on a younger survivor (mentee) through this journey. Participants should not endorse or recommend any physician, medical or non-medical test, procedures, opinions, or in other words give medical advice. The sole purpose of this relationship is to offer encouragement and support through treatment. Under no circumstance should any participant offer any professional, medical or financial assistance from or to each other. By choosing to participate in The National Children’s Cancer Society’s Mentoring Program, I agree: To carefully read the Mentor Handbook. To follow all the rules and requirements outlined in the program. To be flexible and provide the necessary support to help my mentee succeed. To make the commitment during one school year to be a mentor. To contact my mentee at least once a week through whatever source of communication we both agree upon. That working with my mentee may require some parent input. To be on time and consistent with scheduled meetings with mentee. If changes need to be made, give at least 24 hour notice. To keep any information that the mentee tells me confidential except if it may cause him/her or others harm. That as a mentor I will not discuss or encourage any illegal, immoral or unethical behavior with my mentee and will inform the program coordinator of any behavior or discussion that may be viewed as illegal, immoral or unethical. To never discuss the use of alcohol, tobacco or controlled substance with the mentee. To inform the program coordinator of any difficulties or concerns that may arise in the relationship. That in the event there is a crisis and I feel it is a life-threatening situation: I will follow the procedure outlined in the Mentor Handbook. To respond to monthly email check-in by the program coordinator. To participate in the closure process when the time comes. Please check off each of the following:* I have read the Mentor Handbook and discussed any questions I had with the program coordinator. I agree to a background check. I understand that upon match closure, future contact with my mentee is beyond the scope of The National Children’s Cancer Society and may happen only by the mutual consent of the mentor, mentee and parent/guardian. Consent*By checking the box below, I acknowledge that I have read the release and fully understand the contents, meaning and impact. I agree to follow all the above stipulations of this program as well as any other conditions as instructed by the Program Coordinator at this time or in the future. (If the participant is a minor (under age 18) the parent or legal guardian must agree to the conditions outlined here). By clicking “submit,” I provide my signature expressly consenting to contact from NCCS or its subsidiaries, affiliates, or agents at the number I provided regarding products or services via live, automated or prerecorded telephone call, text message, or email. I understand that my telephone company may impose charges on me for these contacts, and I am not required to enter into this agreement as a condition of purchasing property, goods, or services. I understand that I can revoke this consent at any time.
