Request a Buddy
Tells us about your contact information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Other
Date of Birth
*
-
Month
-
Day
Year
Date
How did you hear about the Buddy Program?
Tell us about your role in the transplant community
Please pick one:
I am pre-transplant
I am a caregiver
I am a potential living donor
I am a donor family member
What will you be having transplanted?
What is your diagnosis causing organ failure?
When did your love one pass away?
Where will you have your transplant?
Do you volunteer with any other transplant organizations?
Yes
No
If yes, what other organization do you volunteer with? (please list them all)
Tell us more about your interests in becoming a buddy
Who are you interested in being a buddy with?
Please Select
A recipient
A caregiver/family member
A living donor
A donor family
What kind of communication would you prefer to have with your buddy?
Phone conversation
Virtual Communication (ex. Zoom, Google Meets, Messenger calls)
In-person
Whatever they prefer
All of the above
How often would you prefer to be in contact with your buddy?
Please Select
Daily
Weekly
Monthly
once or twice a month
I don't know
Do you have a preference of gender?
Yes, I would like my buddy to be the same gender as me
No, it doesn't matter
Are you participating in any other buddy/mentorship program right now?
Yes
No
If yes, where?
Tell us a little bit more about you
Tell us a little bit about your transplant journey so far
What are you hoping to get out of having a buddy?
Are you looking for something specific in a buddy?
We will try to match you up with a buddy as closely as we can to your specifications. Please share anything that you would like us to know about you that will help us find the perfect match
Agreements
I understand that I am in no way required to continue with the buddy program, or if I feel that my buddy is not the right fit for me, I can exit the program or request a different buddy.
Yes, I understand
No, I do not understand
I understand that this questionnaire does not automatically enroll me into the Buddy Program and I will need to watch a short video before I am enrolled.
Yes, I understand
No, I do not understand
Signature
Submit
Should be Empty: