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Connect-In Peer Mentoring Application - Mentee
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* Indicates required question
Email
*
Your email
First and Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone Number
*
Your answer
Do you have a spinal cord injury?
*
Yes
No
Other
If yes, What is your level?
Your answer
What was the cause of SCI?
Your answer
Complete or Incomplete
Complete
Incomplete
Are you a caregiver/family member?
*
Yes
No
If yes, what is your role?
Your answer
Preferred Contact Method
*
Phone Call
Text
Email
Required
Anything specific you would like to see in a mentor? (gender, age, race, level, cause, etc)
*
Your answer
Anything specific you would like to address with a mentor?
*
Your answer
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