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BIASC Peer Mentor Program Interest Form

BIASC Peer Mentor Program Interest Form

A peer mentorship program is a program that includes one or more people of similar experience working together to help each other grow through support.
A peer is someone that has a shared experience. A mentor is someone that shares a similar experience and helps another person through support and by working together.
Please complete this form if you would like to attend our next BIASC Peer Mentor Training to become a Peer Mentor.
1.Do you have a brain injury?

(This is a requirement for the peer mentor program)(Required.)
2.How old were you when your brain injury happened?(Required.)
3.What is your first and last name?(Required.)
4.What is your phone number and/or email address?

(Note: you will be contacted after submission of this Interest Form. (Required.)
5.What county do you live in?(Required.)
6.How old are you?
7.What is the best time to contact you? (Ex: morning, afternoon, evening)(Required.)
8.Are you available to meet January 5-9th week for one 2 hour virtual training?(Required.)
9.If yes, what day and time works best for you?(Required.)
10.List 2 contacts and their phone numbers and/or emails who would recommend you as a peer mentor(Required.)
11.Questions/ Comments/Additional Information