Mentor Application

Mentor Applicaiton

We are thrilled to see your interest in mentorship! As we receive mentee applications we will aim to pair mentors & mentees based on goals, interests, and disability. As a mentor you will be expected to check-in with your mentee either bi-weekly or monthly and attend 4 events/year.
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Age*
Address*
Mentor Questions
How often would you be available to check-in/meet up with your mentee?*

WeeklyBi-WeeklyMonthly
Were you ever an In-Patient at the Rehabilitation Hospital?*

YesNo
How comfortable are you mentoring within the Rehabilitation Hospital?*

1

2

3

4

5

1 is Not Comfortable, 5 is Fully Comfortable
How comfortable are you mentoring within the community?*

1

2

3

4

5

1 is Not Comfortable, 5 is Fully Comfortable
What do you hope to gain/achieve as a mentor?*
Please list any previous mentorship experience*
Do you have any interest in having a mentor?*

YesNo
Which of the following areas would you be comfortable offering advice/resources?*

EducationEmploymentDriving/TransportationParasportsExerciseIndependently LivingPersonal CareTravelFinances/Grants
Disability Related Questions

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

Neuromuscular DiseaseMSALSSpinal Cord InjuryParaplegiaQuadraplegiaSpina BifidaCerebral PalsyArthritisUndiagnosedTraumatic InjuryAmputation (upper limb)ABI/TBIStrokeAmputation (lower limb)Other
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 mentee 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 Parasport experience?*

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 mentee 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)*
Should be Empty:

Mentor Applicaiton

Mentor Questions

Disability Related Questions

Interests

Goals