Request a Mentor

Who is filling out this application? Please select an option.

Name of NCH Staff: Please enter a name.

Department of NCH Staff: Please enter a department.

NCH Staff Phone #: Please enter a phone number.

Personal Information

First Name Please enter a First Name.

Middle Name

Last Name Please enter a Last Name.

Address

Address 1 Please enter an Address.

Address 2

City Please enter a City.

State Please select a State.

Zip Code Please enter a Zip Code.

County Please enter a County.

Contact Information

Cell Number

Please enter a Cell Phone Number.

Home Phone Number

Please enter a Home Phone Number.

Email Address

Best Days to Contact

Best Time to Contact

Primary Language Please select a Primary Language.

Secondary Language

Nationwide Children's Hospital (NCH)

My child is currently or was previously a patient at NCH

Tell us what you hope to gain through the Connecting Families program Please enter what you hope to gain.

Primary area of interest Please select a Primary area of interest.

Tell us about other specialty areas of interest

Child Details

Child {{$index + 1}}

First Name Please enter a First Name.

Last Name Please enter a Last Name.

Date of birth (MM/DD/YYYY) Please enter a valid Date of birth.

Sex Please select a Sex.

Diagnosis Please select a Diagnosis.

Year of Diagnosis Please select a Year of Diagnosis.

The Release of Information:

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.

Thank you for submitting an Application