Gutsy Peer Support

Gutsy Peer Support Mentee Application Form

First Name*:	(if you do not feel comfortable providing your first name, please provide a name that you’d prefer for us to share with your mentor)
Last Name:
Email*:	(please note, this email address will be shared with one of our volunteer mentors)
Confirm Email*:
Phone:	( ) - Second three digits Last four digits
Address:
City/Town:
Province/Territory:
Postal Code*:
What best describes your reason for seeking peer support?*:	I am a caregiver for someone living with Crohn’s or colitis I am newly diagnosed with Crohn’s or colitis My diagnosis or life situation has recently changed Other (Choose one only)
If you selected "Other" above, please specify:
What duration of support are you looking for?*:	I only have a few questions (1-2 weeks of support) I am looking for short term support (1-2 months) I am looking for long term support (3+ months) I don’t know/unsure
What is your age? :	Under 18 18-24 25-34 35-44 45-54 55-64 65-74 75+ Choose one only
If you are a caregiver for someone with Crohn’s or colitis, what is your dependent’s age? :	Under 5 5-12 13-17 18-24 25-34 35-44 45-54 55-64 65-74 75+ Choose one only
What is your gender:	Male Female Other
Would you prefer to be connected with a mentor of the same gender as you?:	Yes Doesn't matter
What language(s) do you feel comfortable communicating in (select all that apply):	English French
Which option best describes you? :	Employed Seeking employment Not employed, not seeking employment Retired Student Other
If you selected "Other" above, please specify:
What is your (or your dependent’s) current diagnosis?*:	Crohn’s disease Ulcerative colitis Indeterminate colitis Other
If you selected "Other", please specify:	please provide specific information if you selected "Other" from the dropdown above
Can we share your above diagnosis information with your mentor?:	Yes No
What year were you first diagnosed?:	(please indicate calendar year)
What is your current disease severity? :	Mild (i.e., my disease rarely affects day-to-day activities) Moderate (i.e., my disease sometimes affects day-to-day activities) Severe (i.e., my disease most often affects day-to-day activities) Don't know/other
Are there any specific topics that you would be most interested in speaking with a mentor about, based on your current needs (select the three most important)? :	Time and/or stress management Fertility and/or pregnancy issues Relationship issues Living with an ostomy Surgery (please specify which type/types of surgery below) Workplace issues School issues Travel
If you selected "Surgery" above, please specify:	Please specify which types of surgery
Is there anything else you would like us to share with your mentor?:	For example, what do you hope to get out of participating in this program?
Waiver*:	By checking this box, I acknowledge that I have read and agree to the waiver below.
Security code:	Enter security code:

Waiver

I give my informed consent to my participation in the Gutsy Peer Support Program (the "Program") facilitated by Crohn's and Colitis Canada ("CCC") as a mentee and my authorization to CCC to locate a suitable mentor for me in the Program.

I certify that the information provided to CCC during the application process is complete and accurate, and that I am not impersonating any person, or otherwise misleading CCC with respect to any information that I have provided. I will promptly update any of the information that I have provided so that the information that I have provided remains complete and accurate at all times.

I agree to follow, as applicable, all of the procedures and guidelines outlined by CCC for the Program and understand that if I do not follow these procedures and guidelines, CCC may remove me from the program and terminate the mentoring relationship.

I agree, at all times, to respect the privacy and dignity of the CCC mentor, volunteers and staff and the mission, vision and values of CCC will be followed in accordance with CCC's policies, standards and guidelines.

I understand that my CCC mentor must not give medical advice (including opinions, comments and suggestions that personalize medical information and influence treatment decisions) and will only share information about their personal experiences of living with (or caring for someone with) Crohn’s disease or ulcerative colitis.

I will openly communicate with the Program Coordinator if requested and I will inform the Program Coordinator if I observe any difficulties or have areas of concern that arise in the mentor relationship. If I am unable to communicate difficulties or areas of concern to the Program Coordinator, I will communicate those difficulties or areas of concern by contacting CCC directly.

I understand that CCC may terminate the Program or my involvement in it for any reason at any time including any breach of these obligations.

I agree not to make statements, written or verbal, or cause or encourage others to make any statement, written or verbal, to defame, disparage, or in any way criticize the personal or business reputation, practices or conduct of CCC, its employees, directors, officers and volunteers. I acknowledge and agree that this prohibition extends to statements, written or verbal, made to anyone, including but not limited to news media, any board of directors or advisory board of directors, industry analysts, competitors, strategic partners, vendors, employees and volunteers (past and present), patients, donors and clients.

I hereby waive any and all claims or proceedings that I may have or may in the future have against Crohn’s and Colitis Canada and its respective directors, officers, employees, agents and representatives, as applicable (collectively, the “Releasees”) and irrevocably release and forever discharge the Releasees from any and all liability for any loss, damage, expense or injury, including death, that I may suffer as a result of participating in the Program, due to any cause whatsoever, including negligence, breach of contract, or breach of any statutory or other duty of care on the part of the Releasees.

The provisions of this Consent shall inure to the benefit of the successors, assigns and legal and personal representatives of the Releasees and shall be binding upon my successors, assigns and legal and personal representatives.

I HAVE READ AND UNDERSTOOD THIS CONSENT AND I AM AWARE THAT BY SIGNING IT I AM WAIVING CERTAIN LEGAL RIGHTS. I HEREBY CONSENT AND AGREE TO THE TERMS AND CONDITIONS OF THIS CONSENT, INCLUDING THE WAIVER and RELEASE PROVISIONS HEREIN.