Become A Mentor Registration

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Programme de mentorat parental

Formulaire d'information sur le parent mentor

Les informations fournies seront utilisées par le Family Support Network of NC et les Trusted Parents uniquement aux fins prévues de jumelage des parents.

Formulaire d'information

Veuillez prendre un moment pour remplir complètement le formulaire.

Parent's Full Name

What city do you reside in?

What county do you live in

Preferred Phone Number

Email Address

Preferred method of contact? (check all that apply) Obligatoire

Phone Call

Text

Best time to be contacted?

Primary language spoken

Occupation

If not parent, please provide name and telephone number of person filling out this form.

Full name of child(ren)/individual with special healthcare needs . (optional)

Age of child

List diagnosis or condition and age at the time child was diagnosis:

NICU?

Yes

If yes, for how long?

Gestational age at birth?

Tell us more about your child(ren) (i.e. educational needs, mobility, medical equipment, adaptive equipment, surgery, specialized living setting, behavior challenges, services, and therapies received, adopted, foster, etc.)

Please include any special concerns you may have for your child

If you have multiple children with special healthcare needs, please list age, gender, and diagnosis below:

There are various ways a Parent Mentor can contribute their time to our program in addition to parent matching. Please indicate which of the following activities are of interest to you Obligatoire

Attend parent meetings for information and/or support

Assist with activities and community events

Serve as a speaker or panelist at a training or workshop

Serve on a board or committee

Volunteer in our office

Other

I give permission for Family Support Network and Trusted Parents to release my name and number to another FSN program affiliated/parent for the sole purpose of making a successful match.

Programme de mentorat parental

Formulaire d'information sur le parent mentor

Formulaire d'information

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