Mentor Application

Mentor Application Form

see link below for mentee application form
Mentor: an experienced and trusted adviser.
Mentee: a person who is advised, trained, or counseled by a mentor.

Dear Young Adult Mentor,

Thank you for your interest in the Cure CMD Young Adult Mentorship Program.

Please complete the following in-depth application to match you with an appropriate mentee. Your mentee may have questions about managing education and employment, or about how to effectively advocate with your healthcare team. As the mentor, we trust that you will be honest and provide constructive advice and feedback while sharing insight on your own experiences as well. We want this to be a productive and rewarding experience.

Note: If the mentor is 17 years of age or younger, participation must be acknowledged by a parent or legal guardian.

Guidelines
- Have open communication and accessibility
- Be a role model
- Collaborate
- Exchange knowledge
- Have mutual respect and trust
- Help achieve goals and challenges
- Have passion and inspiration
- Do not mistreat one another
Please complete the information below.

Note: This is the mentor application. If you'd like to be a mentee, please complete this form. You can sign up for both!
Participant Name:*

First NameLast Name
Participant's age in years:
Gender:

MaleFemaleNon BinaryPrefer not to answerOther
Participant Email Address:*
example@example.com
Please enter email address again:*
example@example.com
Email address does not match.
Parent/Guardian Name:*

First NameLast Name
Parent/Guardian Email Address:*
example@example.com
Please enter email address again:*
example@example.com
Parent/Guardian email address does not match.
Country of Residence:*

Street Address

Street Address Line 2

CityState/Province

Zip Code
State/Province/Territory (if applicable):
please enter a location
Are you fluent in English?*

YesNo
Note: We may not be able to identify a mentee who is fluent in your native language.
Fluency in other languages:
CMD Subtype:*
Current status:*

I am a high school studentI am a college student or recent college graduateI previously attended college and am employedI did not previously attend college and am employedNone of the aboveOther
College/University attended:
Job Title:
Ambulatory Status:*
Breathing Status*
For which topics are interested in PROVIDING peer support:*

Care ManagementHealthcare AdvocacyManaging professional caregiversSchool AdvocacyTransitioning to high schoolTransitioning to collegeIndependent livingFinding a jobEmployment AdvocacyDrivingSocial lifeMental HealthLegislative AdvocacyApplying for/managing state and/or federal aidOther
What do you hope to contribute as a Cure CMD YA Mentor?*
Previous experience as a mentor/positive role-model (not required)?
Other Comments or Match Requests:
Terms

Cure CMD may share my contact information with potential program matches.

Matches are contingent upon others signing up for this program and are not guaranteed.

If my assigned match no longer wishes to continue contact, I will refrain from contacting them further.

I may request a new match at any time, and am not limited to just one match.

Cure CMD may reach out to request impressions about my program experience; I agree to respond to such requests and provide candid responses.

Age 17 years or younger: I have obtained permission from my parent/guardian to participate in this program.

The views and/or advice expressed between peer-support matches do not represent the opinion of Cure CMD. Medical or legal opinions expressed or shared should not be substituted or interpreted as medical or legal advice. Please consult your healthcare provider regarding any health related concerns.
I acknowledge and agree to these terms.
Should be Empty:

Mentor Application Form