First Name
Middle Initial
Surname
Date of Birth
City
Province
Type of Cancer
Hospital/Treatment Centre
Age of Diagnosis
Do you speak another language?
If so, what language(s)?
Phone number
Email
School/Program/ Occupation
1. Please describe why you are interested in serving as a mentor for Childhood Cancer Canada's Teen Connector Site.
2. As a mentor, please describe how you plan on helping teens currently in treatment? How will you make a lasting impact?
3. Please list and describe any previous leadership and/or mentorship experience you have had previously (please include volunteer positions, school/workplace involvement)
(Name or Organization / City, Province / Start Date / End Date / Key Responsibilities)
4.What were the three (3) key lessons that you took away from your leadership and mentorship experiences?
5. If you underwent treatment as a pre-teen or a teen, what were some key questions that you had during your treatment and how would you address them as a mentor with teens who are curently going through the same experience?
6. Please provide us with one reference name (either educational or professional) and their contact information (mailing address, email, and telephone number). *
* Please list someone who is not a direct family member - a professional or educational contact is preferred
