Thank you for your interest in becoming a mentee!

Please complete all fields and submit the request below. We will contact you within 2 business days.

 

PERSONAL INFORMATION
Note: The information you submit here is secure. All communications between your browser and this website are encrypted.
Parent/Guardian's Name: *
Parent/Guardian's Name:
Parent/Guardian's Address: *
Parent/Guardian's Address:
Parent/Guardian's Cell Phone: *
Parent/Guardian's Cell Phone:
Other:
Other:
May we text you to set up an initial phone call? *
ABOUT YOUR CHILD
Child's Name:
Child's Name:
Please provide us with your child's primary diagnosis (the condition that requires the most resources and care) and anything else you wish to share at this time
DEMOGRAPHICAL INFORMATION
For nondiscrimination reporting purposes, only
Child's Date of Birth: *
Child's Date of Birth:
MENTOR PREFERENCES
Please list your preferences as they pertain to your child’s mentor
Do you have a specific person in mind whom you’d like to mentor your child? *
How did you hear about MedMentor? *
Please select all that apply
I acknowledge that by clicking the Submit button below, I am agreeing to exchange limited personal health information about my child with MedMentor. Further, I understand that basic information about my child will be anonymously (without name or street address) shared with a potential medmentor to aid in determining a suitable match. Once a match is determined, my child's identity and other relevant information about him/her, including his/her health information, will be shared with his/her medmentor to the extent it aids in facilitating a successful match. *
Today's Date: *
Today's Date:
By clicking on the submit button you are authorizing MedMentor to add you to their mailing list and contact you by either mail, phone and/or email.