One-On-One Mentor Application

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Dear Potential Mentor:

Thank you for your interest in the NICU Helping Hands One‐On‐One Mentor program. This mentor program is only possible because of parents like you who have made the NICU journey and are willing to selflessly give back and help others. You have a unique perspective that is incredibly helpful for current NICU families to hear and experience. There is no doubt that you are making a significant difference in a family’s life through this program.

The One­‐on­‐One Mentor program is a specialized program that provides current NICU families with a mentor to provide support and guide them through the rollercoaster of the NICU. We work to pair current families with a graduate family that had a baby with a similar diagnosis, gestational age, etc. The goal is not to have you “fix” their problems but rather to be someone for them to talk to and encourage them when the tough times come their way.

To be eligible to volunteer you must first fill out the volunteer application. Once you have completed it please mail, fax, or email your application back to NICU Helping Hands Mentor Program. Once we receive your application, you will be contacted in order to set-­‐up an interview. After that, we will be in touch with you to discuss your specific time commitment and opportunities for you to connect with current NICU families. This specific program requires those interested attend a specialized half day training designed for a peer mentor. Our next training session for one-­‐on-­‐one mentors will be held in the fall. Dates will be emailed to those who have submitted applications for this program.

Again, thank you for your interest in NICU Helping Hands. If you have any questions, please do not hesitate to contact us.

Sincerely,

Lisa Grubbs, President
NICU Helping Hands
3023 S. University Drive, Suite 211
817‐688‐5191
[email protected]
www.nicuhelpinghands.org

Mentor Application

Step 1 of 6

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  • Personal Information

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  • Child #1 Information

  • Child #2 Information

  • Child #3 Information

  • Child #4 Information

  • Volunteer Information

    We need peer mentors for parents who are experiencing an antepartum stay, a NICU hospitalization or the loss of a baby. If you have experienced any of these things we need YOU. We require that a mentor be post-experience a minimum of two years before serving as a NICU Helping Hands’ One-on-One Mentor. Please answer the following questions as they pertain to your experience.
  • Experience

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  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Have you ever been charged with or convicted of the following:

  • Please List 3 References

    (please no family members)
  • Reference #1 Information

  • Reference #2 Information

  • Reference #3 Information

  • NICU Helping Hands has my permission to:

  • By signing below, I affirm that I have answered all questions truthfully. I understand that if any portion of this application is found to be intentionally false, I may be denied the right to volunteer with NICU Helping Hands.
    During the course of serving with NICU Helping Hands, there will be occasions when you may be photographed and/or videotaped by staff, sponsors, corporate representatives, media or others. We request permission for your participation. By initialing below, you may choose to grant or deny NICU Helping Hands permission to use photographs or videotapes of yourself, alone or in groups, in (but not limited to) newspaper articles, newsletters, website, social media, online, brochures, special fundraising activities, scrapbook, videos and photo albums for use in public understanding and support of the NICU Helping Hands program. By granting permission below, you hereby release and hold harmless NICU Helping Hands from any claims, judgments, or demands that may arise from the use of the above referenced photographs and/or video.

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