American Transplant Foundation
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Thank you for taking the first step in becoming a Mentor to others within the transplant community. Your willingness to assist those in need is greatly appreciated.

This form does not require you to sign in. Please click the "Save" button at the top of the page when completed and we will be in touch!

Please fill out this application to the best of your ability, and provide as much information about your transplant journey as you feel comfortable sharing.

We will not share your information with anyone outside of the Foundation. We collect it to match you with the most suitable Mentees.
Please fill out this form and click "Save" to submit your application.
Your Contact Information
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Demographic Information
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*The following information is entirely optional, and submitted with this application at will. Should you provide this information, it will assist the Foundation in the matching process.
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Your Transplant Journey
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Mentorship Preferences
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Most Mentees request the following type of support. Please select which areas you would be comfortable helping a Mentee. Check all that apply
 
 
 
 
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How would you prefer to communicate with your mentee? Check all that apply.
 
 
 
What are your preferred contact times - Weekdays
 
 
 
What are your preferred contact times - Weekends
 
 
 
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NOTE: By uploading a photo, I hereby consent to the use of my name and likeness, for the sole purpose of promoting organ donation. I understand that the use of my name and likeness may include, but not be limited to photographs, newspaper articles, brochures, displays, television, radio, or any other public community relations material. I hereby acknowledge that this authorization is volunteered without obligation of any kind on the part of the American Transplant Foundation, its employees, and designated agents. This authorization is given without hope or expectation of reward or compensation of any kind. I hereby waive my right to inspect or approve any materials which may from time to time be created by the American Transplant Foundation and which may include my name, image, photo, likeness, or voice. I, together with my heirs, assigns, agent, guardians, and legal representatives hereby release the American Transplant Foundation from any and all claims, liabilities, and losses that may arise from its use of my name image, photo, likeness, and voice.
Tell Us About Yourself
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Research Questions
The following questions are required, but the answers will not affect your eligibility in the Mentorship Program. Your responses will never be linked to you as an individual and will only be reported in aggregate. Your answers help our foundation ensure this program s availability and may help us tailor assistance to transplant patients in the future.
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Mentor Agreement

AUTHORIZATION FOR MENTORSHIP PROGRAM PARTICIPATION

American Transplant Foundation Living Donation Mentorship Program

I, or my authorized representative, volunteer to serve as a mentor in the American Transplant Foundation (ATF) mentorship program and authorize ATF to share my contact information with individuals considering or pursuing organ donation and transplantation (mentees) who are seeking peer support and guidance.

I understand that:

1. This authorization is voluntary.

2. I have the right to revoke this authorization at any time in writing, except to the extent that action has already been taken based on this authorization.

3. Communications may be electronic, such as email, and such methods may not always be secure. There is no guarantee, assurance, or warranty of confidentiality.

4. I agree to hold the American Transplant Foundation and its officers, directors, employees, and volunteers harmless from any claims or liabilities that may result from electronic communications, my participation as a mentor, or any relationships formed through the mentorship program.

5. As a mentor, I will share my personal experiences, but will not provide medical advice. I understand that mentees are responsible for making their own informed decisions in consultation with qualified medical professionals.

6. I am volunteering to provide informal peer support, not professional counseling or medical services. ATF does not guarantee compatibility with mentees, and I may decline or discontinue any mentorship relationship at any time.

7. I will respect the privacy and confidentiality of mentees and will not share their personal information without their permission.

8. Not all mentor applications are accepted. Acceptance into the mentorship program depends on ATF's capacity to train new mentors at the time of application and other program needs. If accepted, I must complete all required training before serving as a mentor. Even after completing training, ATF cannot guarantee that I will be matched with a mentee, contacted to move forward with mentorship opportunities, or that a mentorship relationship will be established.
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If the Mentor is a minor, the undersigned Parent/Guardian agrees that he/she has read the “Mentor Disclaimer and Release” and understand and agrees to ATF s policies relating to the 1+1=LIFE Mentorship Program. The Parent/Guardian consents to the minor s participation in the 1+1=LIFE Peer Mentorship Program.
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This program is completely free to those who need it. You can support this lifesaving initiative by joining our monthly giving program Save a Life Giving Club. Any amount makes a big impact!

Please press the green "Save" button near the top of the screen to submit. Thank you!
By submitting this application, you consent to the American Transplant Foundation contacting you in the future, when need be.

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