Volunteer Virtual Mentor Application

Personal Information

* Last Name

* First Name

Middle Name

* Date of Birth

Citizenship Status:

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?

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

Select whether you will be volunteering virtually or 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