Volunteer Virtual Mentor Application

New User Details

User ID

User ID (verify)

Password

Password (verify)

Personal Information

* Last Name

* First Name

Middle Name

* Date of Birth

Citizenship Status Required:

U.S. Citizen

Permanent Resident

Neither

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?

Volunteer Type

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):

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