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Mentee Questionnaire
Please complete this questionnaire if you are interested in a potential POQC mentor. Once partnered with a mentor, the contact information provided here will be shared with your mentor, who will reach out about scheduling an introductory meeting.

Participation with mentorship is entirely optional at any point.
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Name: *
Preferred Email Address:
Phone Number:
Would you like to share a little about your experience with cancer as a patient, survivor, and/or caregiver?
Do you have goals for your participation with POQC/MOQC?
Clear selection
If you answered that yes, you have goals, would you like to share what they are?
What other people, places, experiences, or things bring you joy?
What is your preferred method of communication? (select all that apply)
What is your preferred method of meeting?
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If you are open to in-person meetings (which can be so connective!), where are you located (city)?
If you are open to in-person meetings, how far are you willing to drive?
Select the mentors that you would be interested in from the following list (select as many as you'd like):

Link for biographies: https://moqc.org/poqc-mentorship-program/
Tracey Cargill-Smith
Diane Drago
Mike Harrison
Sharon Kim
Steve Clark
First Choice
Second Choice
Third Choice
Fourth Choice
Fifth Choice
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May we share your contact information with your selected mentor? *
Do you  have any additional questions or comments? Is there anything else you'd like us to know that would make you feel more comfortable?
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