Application Form for Mentors

(Accepting applications until late August: interviews will be scheduled between July - August)

*Required Inputs

Name *

E-mail:*

House Address: *

City: *

Province: *

Postal Code: *

Phone #:

Preferred Method of Contact:

Year of Birth:

1. Are you a caregiver mentor? (If No, skip to question 5)
YesNo

2. Please describe your relationship to the individual with a chronic condition/disability, as well as your role providing care?

3. Please describe the individual with a chronic condition/disability whom you provide care for? (e.g. age, individual_condition issues etc.)

4. As a caregiver mentor, you will be sharing details with students about the individual you care for and their illness. Are you able to obtain the written agreement (assent) from this individual to be able to participate in the UBC Health Mentors Program?
YesNo

If no, please explain:

5. What are the main health/disability issues that you would like to share with students as a mentor?

6. Indicate which health professionals have had a role in the care of yourself.
Or if you are a caregiver, indicate which health professionals have had a role in the care of the individual you look after:

I see/have seen...

Dentist

Dietician

Nurse

Occupational Therapist

Pharmacist

Physical Therapist

Physician/Doctor of Medicine

Social Worker

Speech-Language Pathologist

Audiologist

Other health professional(s)

7. How did you hear about the Health Mentors Program?

8. Why are you interested in becoming a health mentor? What will you bring to this role?

9. What benefit(s) do you expect you will gain from being a health mentor?

10. Please name any relevant patient/community organizations you are a member of and your role:

11. What is your occupation?

12. Do you have any experience leading/facilitating a group?

13. Do you have any experience working with UBC or other students?

14. Where would you prefer to meet with students?

15. What is your usual form of transportation?

16. Are there any health issues or other concerns that would require special accommodation in order for you to participate in the Health Mentors Program?

17. Are you able to commit to the time requirements of this 9-month program, including the mandatory orientation expected to be on September 25, 2023 (Monday) at the Croatian Cultural Centre and the symposium in early April 2024?

18. Are you / Have you been a Health Care Professional? If yes, when were you last in practice?

Please provide two references (work, professional, volunteer, or character):

Reference Name 1:

Phone #:

E-mail:

Relationship:

Business/Organization (if applicable):

Reference Name 2:

Phone #:

E-mail:

Relationship:

Business/Organization (if applicable):

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