Mother MentorRegistration paperworkIf the idea of becoming a Mentor speaks to you please fill out the application and one of our Comfort and Care supervisors will contact you. Name * First Name Last Name 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 Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Race/ethnicity that best describes you * American Indian / Alaska Native Asian Black / African American White - Non-Hispanic White - Hispanic Hispanic / Latino Native Hawaiian / Pacific Islander Multi-Racial Middle Eastern / North African Other Prefer not to say 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 At what age were you or your child diagnosed? What was the diagnosis? Describe where you are on your journey dealing with childhood cancer or life-threatening disease. Please provide as much information as you are comfortable sharing. * 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 * 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 Jessica@amandahope.org with any questions or concerns. By checking this box, I agree with the statment above Thank you!
