Becoming a Mentor
Thank you for your interest in becoming a mentor!
Please complete all fields and submit the request below. We will contact you within 2 business days.
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Can we text you to set up an initial phone call?
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Date of Birth:
Date of Birth:
Please describe your previous experience below
Please list your primary diagnosis (the condition that requires the most resources and care) along with anything else you wish to share at this time.
Why do you wish to volunteer at MedMentor?
What do you like to do for fun?
How did you hear about MedMentor?
Please select all that apply
Internet Ad or Search Engine (Google, Bing, etc.)
Word of Mouth
Adult Specialty Clinic
None of the above
I acknowledge that by clicking the Submit button below, I am agreeing to exchange limited personal health information about myself with MedMentor. I authorize MedMentor to obtain any needed information from the references I provided within this application (including additional health information). Further, I understand that basic information about myself will be anonymously (without name or street address) shared with a potential mentee and his/her parents to aid in determining a suitable match. Once a match is determined, my identity and other relevant information about me, including my health information, will be shared with my mentee and his/her parents to the extent it aids in facilitating a successful match.
By clicking on the submit button you are authorizing MedMentor to add you to their mailing list and contact you by mail, phone and/or email.