Registration Form for Students

An e-mail will be sent to confirm your registration

Note for UBC Pharmacy students: Participation in the Health Mentors Program is only through the elective PHRM 300K, coordinated by Dr. Ingrid Price.

*Required Inputs

Contact Information:

First Name: *

Last Name: *

Preferred Name:

Phone #:*

E-mail: *

House Address: *

City: *

Province: *

Postal Code: *

Program of Study: *

Year: *

Campus-Wide Login (CWL):*

UBC Student #:*

Please list any non-English languages that you speak fluently:

Please confirm the following:

I have read the information sheet and I will commit to the program requirements.

Orientation Session:

Attendance at the Health Mentors orientation session is required to participate in the program. It will be held on September 29, 2025 (Monday) at 6:00pm - 8:00pm at the Italian Cultural Centre in Vancouver. For students in the distributed sites, an online Zoom orientation will be scheduled for early October
I can confirm my availability

Refreshments will be provided at the orientation session. Please indicate any dietary restrictions you may have:

Chronic condition / disability preference:

We have recruited Health Mentors with a variety of conditions and their caregivers. If you have a particular preference (e.g. because a particular condition is especially relevant to your discipline), please indicate first, second and third preference by selecting 1, 2, and 3 beside each choice, or select “no preference”. Some mentors have several health problems: we have only listed the primary one here. Please note we cannot guarantee that you will be matched to your preference.

No Preference

[group health_mentor_preferences]

First Preference:

Second Preference:

Third Preference:

[/group]

Location preference:

Most mentors have indicated that they are willing to travel for meetings. However, some meetings may take place in or near the mentor’s home.
If you have a preferred location, please select first, second and third preference from the dropdown list or select No Preference.Please note we cannot guarantee that you will be matched to your preference.

No Preference

[group travel_preferences]

First Preference:

Second Preference:

Third Preference:

[/group]

Special Considerations:

Format preference:

Please indicate your preference for the format of group meetings. Please note we cannot guarantee that you will be matched to your preference.

No PreferenceIn PersonVirtual

I consent to my data being stored in line with our Privacy Policy Guidelines
Please leave this field empty.