Mentee Registration

Mentee Registration

We are thrilled to see you take the next step towards achieving your goals. Through mentorship you will be paired based on your interests, goals, and disability. Mentorship includes 1-1 pairing and invites to quarterly events/gatherings.
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Age*
Address*
Preferred method of contact

Phone callMobile TextMessenger FB/instagram
Are you currently an In-Patient?*

YesNo
Disability Related Questions

We will be pairing you up with a mentor based on disability, interests, and goals
Select all that best describe your disability*

Neuromuscular DiseaseMSALSSpinal Cord InjuryParaplegiaQuadraplegiaSpina BifidaCerebral PalsyArthritisUndiagnosedTraumatic InjuryAmputation (upper limb)Amputation (lower limb)ABI/TBIStrokeOther
Do you use any mobility aids?*

NoneCaneWalkerManual WheelchairPower WheelchairScooterOther
How long since your disability onset/occurred?*

1-2 months3-5 months6 months - 1 year1-2 years2-4 years5-10 years10-20 years20+ yearsLifelong
Is there anything else about your disability you want to share? *
Interests

We will be pairing you up with a mentor based on disability, interests, and goals
Which of the following hobbies interest you?*

MoviesTV ShowsArts & CraftsFibre Arts (crochet, knitting, felting)Playing SportsDrivingWatching SportsOutdoor AdventuresWritingPainting/DrawingVideo GamesBoard Games/Card GamesPuzzlesMusicPlaying an instrumentDancing
Do you have any interest in Parasports?*

NoWheelchair RugbyWheelchair BasketballWheelchair TennisSailingSurfingWater SkiingSnow SkiingSnow BoardingBocciaEquestrianRowingCanoeingKayakingTriathalonAthletics (Racing, Javelin, Discuss, Shot Put, Club)Sitting VolleyballVolt Hockey (Wheelchair Floor Hockey) - coming soon to NSOther
Tell us more about your interests! (ex: if you selected movies, which genres do you like?)*
Goals

We will be pairing you up with a mentor based on disability, interests, and goals
List 3 goal you have (These can be skills, hobbies, employment, recovery, education, sports, family, ect. - think big and small)*
Which of the following areas would you want advice/resources?*

EducationEmploymentDriving/TransportationParasportsExerciseIndependently LivingPersonal CareTravelFinances/GrantsBecoming a Mentor
What do you hope to achieve through the mentorship program?*
Should be Empty:

Mentee Registration

Disability Related Questions

Interests

Goals