Bone Sarcoma Peer Support Mentor Form

Request to be a Mentor

To request to be a mentor please complete the details below... the more info you can provide the better the match
What's your first name?*
Do you use a preferred name?
What's your surname?
Bone Sarcoma Peer Support will need to call you to discuss your request to become a mentor. Please provide a phone number below.
Can you tell us your preferred contact number?*
How would you like Bone Sarcoma Peer Support to send other information

EmailPost
What is your email address?*

Confirmation EmailWe'll use this if you ask us to email you
Can you tell us your address?*

Street Address

Street Address Line 2

CityCounty

Post Code

Your information

All of the information is optional but the more you can provide the better the match we can make
What is your first/preferred language?
We'll use this to match you with someone that speaks your language
Are you fluent in other languages? If so, what are they?
We'll use this to match you with someone that speaks your language
How would you describe your ethnicity?
We only use this info to create better matches
How would you describe your gender?
We only use this info to create better matches
Is there a gender you would prefer to be matched with?
We hate to be rude, but how old are you?
Unfortunately we do not currently offer the service for those under 18. We'd really like your support so please continue your request when you have turned 18.
Can you please provide your postcode?
How frequently would you be willing to provide support?
How would you prefer peers to contact you?*

EmailPhoneText/WhatsApp etcVideo ChatIn person^
^Please note this may not be possible in all instances
What is your email address?

Confirmation Emailexample@example.com

Your Sarcoma

Help us to understand your Sarcoma so that we can match you with an appropriate mentee
Which type of Bone Sarcoma were you diagnosed with?
What year were you diagnosed?
Have you had chemotherapy?
Are you expecting to have chemotherapy?
What stage are you at with the chemotherapy?
Have you had surgery?
Are you planning to have surgery?
How many surgeries have you had?
What year did you have the surgery for removing the tumour?
What type of surgery did you have to remove the tumour?
What type of excision did you have?
What type of endoprosthetic replacement did you have?
What type of amputation/disarticulation did you have?
What types of allograft did you have?
What type of reconstruction did you have?
Can you describe the surgery that you had?
What was your last major surgery?
What type of excision did you have?
What type of endoprosthetic replacement did you have?
What type of amputation/disarticulation did you have?
What types of allograft did you have?
What type of reconstruction did you have?
Can you describe the surgery that you had?
Are there any other surgeries of significance?
What type of excision did you have?
What type of endoprosthetic replacement did you have?
What type of amputation/disarticulation did you have?
What type of allograft will you have?
What type of reconstruction did you have?
Can you describe the surgery that you had?
Do you have anymore surgeries planned?
What's the surgery that's planned?
What type of excision will you have?
What type of endoprosthetic replacement will you have?
What type of amputation/disarticulation will you have?
What type of allograft will you have?
What type of reconstruction will you have?
Can you describe the surgery that you will have?
Have you had or are planning to have any other forms of treatment?

Proton beam therapyTargeted drugs/ trialsImmunotherapyOther
Is there anything else from your condition and/or treatment that you think would be useful for a mentee?
Think about things like pain, recurrent infections or physical limitations etc
Would you like to share with us the reason you are looking to be a mentor?
Think about what support you may want to give eg practical advice, emotional support etc

Confirm your request
Bone Sarcoma Peer Support would like your consent to use the information you have provided.

We will use your data for the following purposes:
- To communicate with you
- To match you with a mentee
- To connect you with a mentee
- To promote, administer and evaluate the mentoring service
- To improve our operation
- For record keeping

We need to share your data with prospective mentees for the purpose of matching and connecting you.

For full details of how BSPS uses your information, please refer to our Privacy Notice.

You are fully in control of the decision to give consent and, if you change your mind, you can withdraw consent at any time by emailing hello@peer-support.co.uk or telephoning 0330 133 4314.

Please tick the box below if you give consent to Bone Sarcoma Peer Support to use your data.
I consent
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Request to be a Mentor

Your information

Your Sarcoma

Confirm your request