Jefferson InterProfessional Education Center (JCIPE)
Health Mentors Application

 
 
Name:
Age:
Health Condition(s) and/or Disability:
Address:
City:
State:
Zipcode:
Phone Number (Primary): 
Phone Number (Secondary): 
Email Address:
Emergency Contact Name:
Emergency Contact Phone Number:
Ethnic Background (optional):
Have you ever acted as a caregiver to someone with a chronic condition? Yes
No
If yes, what was your relationship to that individual,
and what was his/her condition?		 Spouse
Family Member
Friend
Other (please specify):
Condition:
I am able to make accommodations to come to Jefferson's campus: Yes
No
I am able to make accommodations to come to Jefferson's Hamilton Building
(1001 Locust Street, Philadelphia, PA 19107).		 Yes
No

If yes, I would like:

    Tokens
    Parking Pass
    ParaTransit
I am available from 12-2pm on the following Mondays (check all that apply): For Meeting 2:
Feb. 25, 2013
Mar. 18, 2013
Mar. 25, 2013
Apr. 1, 2013
I will be away: (vacation, extended period)
It is difficult for me to walk to another building on campus to meet with my students after lunch. Yes
No
Are you willing to take on an additional team of students? Yes
No
Which of the following is your preferred method of contact
for receiving updates about the program?		 Email
Letter
Newsletter
Health Mentors Website
Other (please specify):
How did you hear about the Health Mentors Program? Health Mentor
Friend
Health Care Provider
Family
Co-worker
Health Mentors Newsletter
Other (Please specify):
Do you know anyone else who is interested to become a Health Mentor?
Please provide their name and contact information:
e-mail address, phone or mailing address)