New Customer Registration Form

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.
Customer Details:
Full Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Age
What is your preferred pronouns
For example: He, She, They, Them
Preferred Method of Contact
Are you currently an In-Patient
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

Other
Do you use any mobility aids?
How long since your disability onset/occurred?
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?
Do you have any interest in Parasports?
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?
What do you hope to achieve through the mentorship program?
*Code of Conduct- I understand that this society is run and attended by persons on a voluntary basis. I agree to treat everyone with courtesy and respect. Behaviour deemed inappropriate may result in my removal from programs.
Should be Empty:

Mentee Registration

Disability Related Questions

Interests

Goals