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 {{$index + 1}}
Please enter a First Name.
Please enter a Last Name.
Please select a Referred By.
Please enter who referred you.
Please enter who referred you.
Child Details
Child {{$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.
In order to get a mentor or In order to become a mentor we must have your permission to share information about your child’s health.
Follow The Steps Below:
Click Submit Application, then the consent form will come up.
Make sure the consent form is correct.
Click the green “Add Signature” link.
Then use the mouse to sign your name in the box.
Click “Today” to add the date.
Click next page.
Click the checkbox to certify all information is correct.
Click the check box to submit.
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: