Apply to Become a Peer Mentor

What is your name? *

First

Last

Your email *

Your cell phone *

Your Home (City and State/Country) *

Child's name *

Child's diagnosis *

What is your relationship to the child? *Please chooseParent/Primary CaregiverSiblingGrandparentOther

Where was the primary location the child treated? *

Child's age at the time of their death *

Child's date of death *

How did you learn about Zach's Bridge?

• Google or other Internet search
• A social worker or other medical professional
• Instagram, Facebook or other social media
• Someone else referred me
• Other

Your preferred method of communication *

• Text
• Email
• Phone Call
• Any of the Above

Do you speak any languages besides English? *YesNo

What languages do you speak? What is your level of fluency? *

Please share your motivation for becoming a peer mentor *

How do you think peer recipients would benefit from your support?

Are there any situations/people you would not be comfortable matching with?

Is there anything else you think is important for us to know?

Permission to Share *

• I am authorized to share this information with Zach's Bridge.

Apply To Be A Peer Mentor