Mentor Application Form
Thank you for your interest in applying to be a Mentor for our Peer Mentorship Program.

Please answer the questions fully and to the best of your ability. Your answers will not only help us in our selection process but if accepted will help us match you with mentees.

You will be contacted by our Community Advocate regarding the next steps.
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Email *
First Name *
Last Name *
Age *
In what country will you be residing during this program? *
When communicating with you, which pronoun do you prefer? *
What type of diabetes do you have? *
When were you diagnosed with Diabetes? *
How do you currently manage your diabetes? Please check all that apply. *
Required
Who helps you manage your diabetes? Please check all that currently apply. *
Required
Everyone manages diabetes differently - it's not a one size fits all approach.  How do you define success? How are you living successfully with diabetes? *
Why are you interested in becoming a mentor? *
What previous experience (can be life or work related) do you have that you think will make you a strong mentor candidate and why? *
Have you ever worked or volunteered as a mentor? If so, tell us briefly about the experience. If not, do you have any other volunteer experience you'd like to share? *
Do you have regular access to reliable internet?
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How do you typically access the internet? *
Required
How are you currently engaged with Diabetes Daily? Please check all that apply. *
Required
(Optional) To help us get a sense of who you are, what are your social media handles (your facebook, Instagram, Twitter account)?
Your availability - for weekly meetings (training and Coffee Chats - group conference calls) *
Available
Not Available
Can make if need be
Tuesday Mornings
Tuesday Afternoons
Tuesday Evenings
Wednesday Mornings
Wednesday Afternoons
Wednesday Evenings
Sunday Mornings
Sunday Afternoons
Sunday Evenings
In what time zone will you be residing during this program? *
On a scale of 1 to 10, how would you rate your comfort with technology? *
I'm very green - I have an older computer and/or will need additional training and help.
I'm a Pro - I am comfortable with Google Drive, Social Media (facebook, instagram, twitter), webinar and conference call systems, forums, online calendars, email.
I am interested in applying for a Lead Mentor position. *
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