*First Name *Last Name *Address *City *State *State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming *Zip *Home Phone Cell Phone *Email *Age *Preferred Method of Contact *Preferred Method of Contact Home Phone Cell Phone Email *Start Date of Inpatient Stay *End Date of Inpatient Stay School Activities/Interests/Skills Why do you want to be a Peer Mentor? Have you ever Volunteered at Children’s Specialized Hospital? YesNo If yes, tell us about your experience. Please Provide 1 Reference from Each Area Listed Below: 1. Work/School or Personal *Reference Name *Phone # of Reference *Title of Reference 2. Medical (Rehab Physician or Therapist from CSH) *Reference Name *Phone # of Reference *Title of Reference Please List your Availability *I would like to be considered as a Peer Mentor. I understand that if my interest application is accepted that there is an additional interview process. If accepted as a mentor, I will attend and register with CSH Volunteer services (inclusive of general trainings) and will receive additional training specific peer mentoring. I understand that I must commit to a minimum of 3 mentoring sessions or more. Yes Please confirm security question above