MENTOR APPLICATIONS

Personal Information

Last Name

First Name

Home Address

Home Phone

Cell Phone

Email Address

Date of Birth

Health-Related Information

Are you currently a kidney patient?

Yes

No

Date of Diagnosis

Are you currently a kidney patient?

Yes

No

Are you currently on dialysis?

Yes

No

If yes, since when?

Modality and Name of Dialysis Center

Nephrologist Name

Have you ever had a kidney transplant?

Yes

No

If yes, when?

Name of Transplant Center

Social Worker Name

Volunteer and Background Information

Are you willing to make one-on-one visits to patients who need emotional support?

Yes

No

Are you willing to make phone contact for those not wishing to have a personal visit?

Yes

No

Qualities that might be helpful in your role as a Certified Partner

Why are you volunteering?

What are your major interests and hobbies?

Additional Information

References

References Form

Please provide three references. References must be members of the medical team, other than physician and social worker already provided above. Relatives of the applicant will not be accepted.

Reference 1

Name

Home Address

Phone Number

Email Address

Reference 2

Name

Home Address

Phone Number

Email Address

Reference 3

Name

Home Address

Phone Number

Email Address

Permissions and Signature

The Kidney Foundation of Central Pennsylvania

Lynne Wright, MSW, LSW, Program Coordinator

Suite 134A 900 South Arlington Ave. Harrisburg, PA 17109

717-671-9444

FOR KFCP USE ONLY

Date application received

Date of Training

By Whom

Date of Certification

I give my permission for the KFCP to utilize any of the provided patient health information for the purpose of assessing any need to optimize my learning experience with the Patient & Family Partner Program. I understand that this information may be utilized in a grant funded by the National Kidney Foundation, in conjunction with CNSW to benefit those with disabilities who participate in the Patient & Family Partner Program.

Print Name

Date

Sign Name

Certified Partner Candidate Application Form

Personal Information

Health-Related Information

Volunteer and Background Information

Additional Information

References

Permissions and Signature

Hope and Support for Kidney Patients