Mentees Registration

Mentees Information Form:




Information about person with Alport Syndrome:







Needs of Mentee:



Please check all categories of mentors with whom you would be willing to be partnered.


No Yes

Male Female


a teenager (ages 13 – 19)
a young adult (ages 20 – 30)
an adult (ages 31 – 45)
an older adult (ages 46+)


diagnosed less than 1 year ago
diagnosed 1 – 3 years ago
diagnosed more than 3 years ago


is not in renal failure and not on dialysis
is starting dialysis in the near future
is on dialysis
is a transplant recipient

2. Would you like to be matched with a family member/loved one of a person with a Alport Syndrome?

No Yes


Male Female


a spouse
a parent
a sibling
an extended family member
a mentee, significant other, or close friend


diagnosed less than 1 year ago
diagnosed 1 – 3 years ago
diagnosed more than 3 years ago


is not in renal failure and not on dialysis
is starting dialysis in the near future
is on dialysis
is a transplant recipient



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