Volunteer Virtual Mentor Application

Personal Information

* Last Name

* First Name

Middle Name

* Date of Birth

*Citizenship Status:

U.S. Citizen

Permanent Resident

Neither

*Do you have an F1 Visa?

Current Address:

* Street

* City

*State

* Zip Code

Telephone Number(s) with area code:

Day

Evening / Home

Cell

* E-mail address:

Emergency Contacts

* Name:

* Relationship to you:

Telephone Number:

* Cellular Number:

Physician's Name:

Hospital Affiliation:

Physician's Telephone Number:

Volunteer Information

The following questions will help us get to know you better.

*Are you an employee of UHealth?

Yes

No

*Are you a current University of Miami (UM) student?

Yes

No

*Select whether you will be volunteering virtually or in-person:

Virtual

In-Person

What language(s) do you speak?

Are you a patient, former patient, or a family member of a patient?

When was you or your family member's care experience at UHealth?

Where did you or your family member receive care (check all that apply)?

*We recognize that our mentors have busy lives. How much time are you able to commit to being a mentor?

Are you available to serve as a mentor for at least 1 year?

Other issues (Please describe):

References

Please provide a professional or academic reference below. References from friends or family members will not be accepted.

* Name

* Relationship

* Telephone

* E-mail Address

Signatures

I certify that all statements in this application are true. I also agree that if I am accepted as a volunteer, I will abide by all regulations of UHealth.

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Applicant's Signature