Power of Two Mentor Application Personal Information Question Title * 1. Last Name (Required.) Question Title * 2. First Name (Required.) Question Title * 3. Contact Information (please provide complete mailing address) (Required.) Address * Address 2 City/Town * State/Province * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * Email Address * Phone Number * Question Title * 4. Date of Birth (Required.) Date / Time Date Question Title * 5. To which gender do you most identify? (Please select all that apply) (Required.) Woman Man Non-binary Transgender Prefer not to disclose Something else (please specify) Question Title * 6. What is your race? (Please select all that apply) (Required.) Asian (E. Asian, S. Asian, SE. Asian) Black or African American Middle Eastern or North African Native American Native Hawaiian or Other Pacific Islander White Prefer not to disclose Other self-identities (please specify) Question Title * 7. What is your ethnicity? Please select one (Required.) Hispanic or Latino Not Hispanic or Latino Prefer not to disclose Question Title * 8. Do you identify as an LGBTQIA+ individual? (Required.) Yes No Prefer not to disclose If yes, how do you identify? Question Title * 9. How did you first hear about Power of Two? (Required.) Crohn’s & Colitis Foundation website Social media (Facebook, Instagram, etc.) Crohn’s & Colitis Foundation email or newsletter Local Chapter Healthcare Professional Support group facilitator or other volunteer Online search (Google, etc.) Other (please specify) Next
