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 Educational Background Ethnic Origin African AmericanAsian AmericanCaucasianHispanicNative AmericanOther Referral Source Self-referralHealthcare ProviderRelative / FriendMentor VolunteerCommunity Organization or AgencyOther If you selected other, please specify your referral source Hobbies Language(s) other than English that you speak Most Convenient Days for Volunteer Service SundayMondayTuesdayWednesdayThursdayFridaySaturday Most Convenient Times of Day for Volunteer Service AMPM Occupation Previous Volunteer Experience Special Skills (i.e., sign language, etc) Primary Care Physician's Name Diagnosis Date of Diagnosis Physician Address Street Address City State New YorkAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Treatment (If Applicable) Surgeon's Name Surgeon's Address Street Address City State New YorkAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Oncologist's Name Oncologist's Address Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Type of Surgery (If applicable) Surgery Date Please list treatment that you have received. Please list if you have received chemotherapy, radiation, hormonal, or other treatment. Along with the treatment, please tell us the date and type. Are you currently undergoing treatment? YesNo Additional information to help us best facilitate a mentor 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 newly diagnosed patient who is seeking a mentor? Confirmation (Please type your name)
