Mentee & Diabuddy Sign-Up Form FOR TEENS & YOUNG ADULTS!

Diabetes Youth Families, Insulliance, and UCSF are committed to inspiring and empowering pre-teens, teens, and young adults with diabetes by providing support and understanding through peer-to-peer connections and mentorship. We are teaming up to offer these opportunities to promote supportive connections and community as teens navigate life with diabetes. Once paired, Diabuddies and mentee/mentors are welcome to connect in the ways that feel most comfortable to them whether that be via text, emails, phone, video chat, or in person.

Required Information Information [ ] I am interested in connecting with a teen or young adult buddy of similar age as me with diabetes [ ] I am interested in connecting with a young adult Insulliance mentor with diabetes [ ] Please do your best to pair me with someone in/near the city where I live [ ] Location not important [ ] I am interested in participating in surveys to assess the effectiveness of this program Caregiver’s Name(s): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Primary City, State, Zipcode: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Preferred Phone: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Email: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Teen’s Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Gender: \_\_\_\_\_\_\_\_\_\_ Preferred pronouns: \_\_\_\_\_\_\_\_\_\_\_ Teen’s DOB (MM/DD/YYYY): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date of Diagnosis (MM/YYYY): \_\_\_\_\_\_\_\_\_\_\_\_\_\_ Type of diabetes: [ ] Type 1 [ ] Type 2 UCSF patient (Oakland, Madison Clinic, Walnut Creek, Santa Rosa, Salinas): [ ] Yes [ ] No Teen’s preferred method of communication: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Teen’s contact information: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

###### The following information will help us pair you with a diabuddy or mentor.

Grade / School: Hobbies: Pets: Favorite Music/Band: Favorite Movie: Spirit Animal: My Desired Superpower: Anything else you’d like us to know about you!

By applying to participate in Insulliance, I consent to release the information provided above to Insulliance, my Mentor and/or Diabuddy, and understand that I/my child will be contacted by these entities. I agree to I assume all personal risk and liability for myself and/or my child participating in the Insuliance program. All conversations/medical information shared between mentor/ mentee are to be kept confidential unless both parties agree otherwise, and will not be shared outside of the program unless it is necessary to maintain someone’s personal safety. I am aware that I can opt out of the program and opt out of contact by the organization at any time. Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date (MM/DD/YYYY): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

#### Relationship to person with diabetes: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Please email completed form to Julia Philips, DYF’s Community Program Coordinator at philips@dyf.org or let your care team know if you need support turning in your application.

#### Received by: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Mentor Assigned: Y / N Mentor Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_