Mentor Request Form

Mentor Request Form
Thank you for your interest in our mentoring program! We’re excited to match you with one of our experienced volunteer mentors.

To make this connection, we will share your name and contact information with your assigned mentor. A member of our team will follow up with you once your form is received.

If you have any questions or would like to discuss this further, please email us at peermentors@pkdcure.org.

We look forward to supporting you through this program!
Your Information
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Preferred Phone
YesNo
I have ADPKDI have ARPKDI have a child with ADPKDI have a child with ARPKDI have a family member with PKDMy friend has PKDI care for someone with PKDI have lost a child to PKDI have lost someone to PKDI work in the PKD field (research/medical)I work for a nonprofit in the PKD or kidney spaceI work for a pharmaceutical or biotech companySpontaneous mutationPrefer not to answer
When were you or your family member diagnosed with PKD?*
Living with PKDLiver CystsLiving donor kidney transplantDeceased donor kidney transplantPeritoneal Dialysis (PD)HemodialysisChronic PainLosing a family member to PKDChildren with PKDParticipation in Clinical TrialsAneurysmNephrectomySpontaneous mutationPre-implantation genetic diagnosis
Yes
Yes
Should be Empty:

Mentor Request Form

Your Information