Become a Caregiver Mentor

* indicates a required field

First Name *


Last Name *


Address *


City *


State *


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 *


Date of Birth *

Gender *


Race


What is your relationship with the person diagnosed with cancer? *


Their Gender


Their Type of Cancer *


Their Stage of Cancer


Their Diagnosis Date


Format as mm/yyyy

Date of Their Last Treatment (mm/yyyy)


Treatment

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.

Check all that apply.

Indicate if these issues are still a concern to you.

Check all that apply.

Hospital / Cancer Center


Where was your loved one treated?

Your Marital Status


How many child(ren) do you have?


Birth Year of Youngest Child


Format as yyyy

Birth Year of Oldest Child


Format as yyyy

Your Employment Status during treatment


Your Current Employment Status


Languages Spoken

   

Notes / Interests


Why do you want to be a mentor?


How did you hear about 4th Angel?


Do you have any previous volunteer experience?


Volunteer Program


Program City


Program State


Dates of Service


Volunteer Program 2


Program 2 City


Program 2 State


Dates of Service 2


Have you ever been convicted of a felony or misdemeanor?


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 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.