JCIPE -- Health Mentors Application

Health Mentors Application

Name:
Age:
Health Condition(s) and/or Disability:
Address:
City:
State:
Zipcode:
Phone Number (Primary):
Phone Number (Secondary):
Email Address:
Emergency Contact Name:
Emergency Contact Phone Number:
Ethnic Background (optional):
Have you ever acted as a caregiver to someone with a chronic condition?	Yes No
If yes, what was your relationship to that individual, and what was his/her condition?	Spouse Family Member Friend Other (please specify): Condition:
I am able to make accommodations to come to Jefferson's campus:	Yes No
I am available from 12-2pm on the following Mondays (check all that apply):	For Meeting 1: Oct. 26, 2009 Nov. 2, 2009 Nov. 16, 2009 For Meeting 2: Mar. 8, 2010 Mar. 15, 2010 Apr. 5, 2010 Apr. 12, 2010
I will be away: (vacation, extended period)
Are you willing to take on an additional team of students?	Yes No
Which of the following is your preferred method of contact for receiving updates about the program?	Email Letter Newsletter Health Mentors Website Other (please specify):
How did you hear about the Health Mentors Program?	Health Mentor Friend Health Care Provider Family Co-worker Health Mentors Newsletter Other (Please specify):
Do you know anyone else who is interested to become a Health Mentor? Please provide their name and contact information: e-mail address, phone or mailing address)