Test form - Lung Transplant Foundation

Request a Mentor

To request a recipient or caregiver Mentor from the Lung Transplant Foundation Mentorship Program please complete this form:

Please choose which option applies to you.

I am a lung transplant recipient (or in the process of becoming a recipient) requesting a Mentor

I am a caregiver requesting a Mentor

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Confirm Phone/Mobile

Please provide an alternate contact person for a health check in case we can’t reach you after several attempts:

Alternate Contact First Name

Alternate Contact Last Name

Alternate Contact Email Address

Languages Spoken

English

Spanish

French

Other

Birthdate

Gender

Male

Female

Marital Status

Single

Married

Domestic Partnership

Widowed

If applicable, how many children do you have?

Are you the primary caregiver for the individual?

Yes

Transplant Type

Single Lung

Double Lung

Living Donor

Transplant Status

Transplant Center

Transplant Date

Diagnosis causing organ failure. Check all that apply

Cystic Fibrosis (CF)

Sarcoidosis

Bronchiectasis

Idiopathic Pulmonary Fibrosis (IPF)

Pulmonary Hypertension (PH)

Interstitial Lung Disease (ILD)

Alpha-1 Antitrypsin Deficiency (AAT Deficiency)

Chronic Obstructive Pulmonary Disease (COPD), includes asthma, chronic bronchitis or emphysema

Other

Concerns

Applicant Terms

To be a Mentee in the Lung Transplant Foundation Mentorship Program and I’m free to discontinue at any time, for any reason.
The Mentee-Mentor relationship is based on confidentiality.*
There will be no medical advice discussed.

*General Explanation of Confidentiality Personal information is confidential and will not be disclosed or discussed with anyone other than the Mentorship Manager, Lung Transplant Foundation Executive Director, Lung Transplant Foundation President and assigned volunteer Mentor without permission or authorization from the program participant. General information about the Mentorship Program, policy statements or statistical material that is not identified with any individual or family is not classified as confidential.

Exceptions include: Clear and imminent danger to you or someone else will result in notification of the Mentorship Director, Lung Transplant Foundation Executive Director, Lung Transplant Foundation President and, if deemed necessary, medical personnel directly involved in your care and/or local authorities.

By submitting this form I am aware and am agreeing to the above.

I agree

Applicant Terms

Vision Statement

resources

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