Become a Caregiver Mentor

* indicates a required field First Name * Last Name * Address * City * State * AL AK AS AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY Zip * Home Phone # Format as xxx-xxx-xxxx Work Phone # Format as xxx-xxx-xxxx Cell Phone # Format as xxx-xxx-xxxx Best Time to Call E-Mail * Preferred Method of Contact * No Preference Home Phone Work Phone Cell Phone E-Mail Date of Birth * Date of Birth Date Gender * Male Female Race American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White What is your relationship with the person diagnosed with cancer? * Spouse / Significant Other Parent Child Sibling Other Their Gender Male Female Their Type of Cancer * Their Stage of Cancer 1 2 3 4 Unknown Their Diagnosis Date Format as mm/yyyy Date of Their Last Treatment (mm/yyyy) Treatment Bone Marrow Transplant Chemotherapy (include # of treatments in Notes) Clinical Trial Hormonal Therapy Radiation Surgery Wait & Watch What type of treatment did they receive?  Please check all that apply. If chemotherapy, indicate how many treatments. If radiation, indicate how many treatments. Please indicate which of the following was most stressful for you at the time of diagnosis. Career / Job Emotional Distress Fatigue Fear of Death Fear of Recurrence Fertility Finances Nutritional Concerns Parenting Physical Changes Relationships Sexuality Check all that apply. Indicate if these issues are still a concern to you. Career / Job Emotional Distress Fatigue Fear of Death Fear of Recurrence Fertility Finances Nutritional Concerns Parenting Physical Changes Relationships Sexuality Check all that apply. Hospital / Cancer Center Where was your loved one treated? Your Marital Status Married Single Separated Significant Other Divorced Widowed How many child(ren) do you have? 0 1 2 3 4 5 6 7 8 9 10+ Birth Year of Youngest Child Format as yyyy Birth Year of Oldest Child Format as yyyy Your Employment Status during treatment Full-Time Part-Time Retired Disability Homemaker Other Unemployed Your Current Employment Status Full-Time Part-Time Retired Disability Homemaker Other Unemployed Languages Spoken English Spanish French Sign Language Specify your own value:     Notes / Interests Why do you want to be a mentor? How did you hear about 4th Angel? Internet Brochure Social Worker Nurse Physician Radio/TV/Newspaper Cancer Organization Family/Friends Other Do you have any previous volunteer experience? Yes No Volunteer Program Program City Program State AL AK AS AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY Dates of Service Volunteer Program 2 Program 2 City Program 2 State AL AK AS AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY Dates of Service 2 Have you ever been convicted of a felony or misdemeanor? Yes No A conviction does not necessarily disqualify an applicant. Failure to disclose may result in disqualification or termination. If yes, please describe the offense. Conditions of submission * I agree to following condition of submission I hereby confirm that the information provided in the above web application form is true and complete to the best of my knowledge. I understand that providing false information may disqualify me from consideration as a volunteer. My act of filling out the aforementioned form gives my consent to perform a background check. I will consider all information that I gain in my volunteer position to be confidential. I understand that my volunteer service will be terminated in an event of breach of confidentiality.