Become a Mentor

Personal Information
 
Please enter a First Name.
 
Please enter a Last Name.
 
Please enter an Address.
 
 
Please enter a City.
 
Please select a State.
 
Please enter a Zip Code.
 
Please enter a County.
 
Please enter a valid Date of birth.
 
Please enter an Emergency Contact.
 
Please enter a Contact Phone Number.
 
Please enter a Contact Relationship.
 
Contact Information
 
Please enter a Cell Phone Number.
 
Please enter a Home Phone Number.
 
 
Please select a Primary Language.
 
 
Nationwide Children's Hospital (NCH)
 
Please select a Primary area of interest.
 
 
Please enter your experience.
 
 
 
 
We will need to notify your child’s specialty area of your interest in becoming a Connecting Families Mentor. Please list two NCH staff members that we can contact (staff contact can be social worker, therapist, nurse and/or physician).
 
NCH Reference {{$index + 1}}
Please enter a First Name.
Please enter a Last Name.
 
Please select a Referred By.
 
 
Child Details
 
Child {{$index + 1}}
Please enter a First Name.
Please enter a Last Name.
Please enter a valid Date of birth.
 
Please select a Sex.
Please select a Diagnosis.
Please select a Year of Diagnosis.
 
 
Background
A background check will be performed upon acceptance into Nationwide Children's volunteer program.
 
 
If yes, please complete the following for the most recent conviction:
 
 
Please enter a valid Date.
 
 
 
 
 
 

Thank you for submitting an Application