Auxiliary MentoringTraditional Mentoring Auxiliary Mentoring: Occasional check-ins and messages of encouragement Traditional Mentoring: More consistent check-ins and on-going communication Full Name Email Address Your Address Street Address City State New YorkAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Home Phone Cell Phone Preferred Contact MethodEmailHome PhoneCell Phone Date of Birth Age Marital Status SingleMarriedDivorcedWidowed Sex MaleFemale Children Please include the number of girls or boys and their age(s) at the time of diagnosis Ethnic Origin African AmericanAsian AmericanCaucasianHispanicNative AmericanOther Educational Background Occupation Hobbies Language(s) other than English that you speak Special Skills (i.e., sign language, etc) Previous Volunteer Experience Most Convenient Days for Mentoring SundayMondayTuesdayWednesdayThursdayFridaySaturday Most Convenient Times of Day for Mentoring AMPM Please tell us about your experience as a caregiver Relationship to the Patient Patient's Diagnosis Date of Diagnosis Patient's Treatment (if applicable) Please list if the patient has received chemotherapy, radiation, hormonal, or other treatment. Along with the treatment, please tell us the type. Patient's Prognosis How long were you a caregiver? Are you currently caregiving? YesNo What challenges did you face as a caregiver? Is there something that you do (professionally, recreationally, etc.) or something unique to your experience (with cancer or otherwise) that you feel might help you to connect with a caregiver who is seeking a mentor? Confirmation (Please type your name)
