Community Health Mentor Interest Form Faculty and Staff Program Guidelines, Consent Form and Mentor Information Sheet: Community Health Mentor Contract (PDF). General Information Name Phone Number Email Address Zip Code Eligibility Requirements Are you willing to share your medical history and health care experiences with our health care profession students? Yes No Are you 18 years of age or older? Yes No Do you have a Primary Care Provider Yes No *This is a requirement to be eligible for our program. Are you available on Wednesday afternoons to meet with the students? Yes No Are you able to meet with our students in person or remotely for an hour seven times per year? Yes No *Available dates Do you live within 25 minutes of downtown Phoenix? Yes No *Due to the COVID-19 pandemic, in-person visits will not take place until further notice. Once in-person visits resume, you will have the option to request virtual Zoom visits if desired. If you do not live within 25 minutes, would you be willing to meet our students within 20 minutes of downtown Phoenix at an agreed upon location? Yes No Program Guidelines and Consent Form Have you read through our Program Guidelines? Yes No Have you read through our Program Consent Form? Yes No *Available above How did you hear about our program? Send Copy of Request to My Email CAPTCHA Submit
Program Guidelines, Consent Form and Mentor Information Sheet: Community Health Mentor Contract (PDF). General Information Name Phone Number Email Address Zip Code Eligibility Requirements Are you willing to share your medical history and health care experiences with our health care profession students? Yes No Are you 18 years of age or older? Yes No Do you have a Primary Care Provider Yes No *This is a requirement to be eligible for our program. Are you available on Wednesday afternoons to meet with the students? Yes No Are you able to meet with our students in person or remotely for an hour seven times per year? Yes No *Available dates Do you live within 25 minutes of downtown Phoenix? Yes No *Due to the COVID-19 pandemic, in-person visits will not take place until further notice. Once in-person visits resume, you will have the option to request virtual Zoom visits if desired. If you do not live within 25 minutes, would you be willing to meet our students within 20 minutes of downtown Phoenix at an agreed upon location? Yes No Program Guidelines and Consent Form Have you read through our Program Guidelines? Yes No Have you read through our Program Consent Form? Yes No *Available above How did you hear about our program? Send Copy of Request to My Email CAPTCHA Submit