Mentor Application

If the idea of becoming a Mentor speaks to you please fill out the application below and one of our Comfort and Care supervisors will contact you.

Name

First

Last

have your and

I am

a parent/caregiver of a child diagnosed with cancer or life-threatening disease
a bereaved parent/caregiver
an adult survivor over the age of 18

Preferred method to contact you

Email
Phone
Text
Other

If you are a parent/caregiver, please list the names and ages of all of your children

Describe any unexpected challenges you and your family faced on your journey

In a few sentence, explain why you are interested in becoming an AHRA Mother Mentor.

Please provide additional information that will help us match you with a mentee including any expertise you have in areas such as education, transplant experience, or recurrences.

Mother Mentor Consent

By checking this box, I agree with the statment below

I fully understand that if I am selected to be a Mother Mentor for AHRA, I will receive training from AHRA Comfort and Care staff and will be matched with a mother in need of support. In addition, I agree to adhere to all of the Mother Mentoring Program guidelines as outlined in the training materials and by the Comfort and Care staff. I understand that my involvement in the Mother Mentoring Program is voluntary and I may discontinue participation at any time by contacting a member of Comfort and Care staff. I understand that once a match is made, I will communicate with my mentee in an unsupervised setting. Communication frequency and channels will be determined by me and my mentee. As a participant in the Mother Mentoring Program, I agree to treat my mentee with respect, respond to their messages in a timely manner, and keep private information shared by my mentee confidential between them, myself and the Comfort and Care supervisors. I give AHRA permission to share my contact information with my assigned mentee so that they can reach out to me directly. I understand that it is my responsibility to contact AHRA Comfort and Care staff with any questions or concerns about the Mother Mentoring Program. AHRA believes in the importance of being responsive to the needs of every Mother that is part of our community regardless of their racial/ethnic background. We believe in the importance of a culture that values people of all racial/ethnic backgrounds. We value the many identities that an individual brings to the community and honor and appreciate the intersections of these identities. Our practice values respect, integrity and honesty. We are committed to inclusiveness. We look forward to working with you . Please reach out to Jessica Landfair at [email protected] with any questions or concerns.