Peer-to-Peer Program Application Form (Find a Mentor)

The first step in seeking mentorship at Clearview Cancer Institute is to complete the application form below. Once you complete the form, please make sure to click the continue button. Your application will be reviewed and paired with one of our Peer Mentors within two weeks of submission.

Thank you for your interest in our Peer-to-Peer Program!

-Rebekah Ormond, Volunteer Coordinator

Fields marked with an * are required

Contact Information

Full Name *

Nickname

Street Address *

City *

State *

Zip *

Home Phone *

Cell Phone

Email Address *

Demographic Information

Date of Birth *

Age *

Gender *

Female
Male

Education

I Am A (Please check one)

Patient
Family Member of a Patient
Caregiver of a Patient

Diagnosis

TYPE OF CANCER, STAGE, YEAR OF DIAGNOSIS, AND AGE OF DIAGNOSIS. (IF FAMILY MEMBER, PLEASE ENTER THEIR DIAGNOSIS.) *

References

References may not be members of your family or individuals with whom you reside.

References 1

Name *

Home Phone

Cell Phone

Relationship *

Have you ever been found guilty of a crime? *

Emergency Contact

Full Name *

Home Phone

Cell Phone

Relationship *

Areas of Interest and Experience

BRIEFLY TELL US WHY YOU ARE SEEKING MENTORSHIP WITH ONE OF OUR PEER MENTORS. PLEASE BE SURE TO INCLUDE ANY SPECIFIC QUESTIONS YOU MAY ALREADY HAVE FOR THE MENTOR; FOR EXAMPLE, FIRST DAY OF TREATMENT QUESTIONS, FACILITY LOCATION, DIAGNOSIS RELATED QUESTIONS, ETC. THIS WILL HELP US WITH THE PAIRING PROCESS.

I CERTIFY THAT THE INFORMATION PROVIDED ON THIS APPLICATION IS COMPLETE AND TRUE. I FURTHER ACKNOWLEDGE THAT FALSIFICATION OR OMISSION OF ANY SIGNIFICANT INFORMATION PRESENTED OR REQUESTED ON THIS APPLICATION MAY RESULT IN DISMISSAL. I HEREBY AUTHORIZE CLEARVIEW CANCER INSTITUTE TO REQUEST INFORMATION TO BETTER ASSIST IN PEER MENTOR PAIRING FROM THE INFORMATION I HAVE PROVIDED. *

PLEASE CHECK THE BOX

Your Resources

Cancer
Treatment

UNDERSTAND TREATMENT OPTIONS

Your Resources

Clinical
Trials

Revolutionizing Cancer Care

Your Resources

Lung
Screening

Why Screening Saves Lives

Locations

Volunteer Opportunities