Senior Mentor Volunteer Application

Section 1 of 3: Personal Information

Name*

First Last

Home Phone

Cell Phone

Email

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gender

Male
Female

Birthday*

Ethnicity*

How did you hear about us?*

Emergency Contact*

First Last

Emergency Contact Phone*

Emergency Contact Relationship

Marital Status

Have you ever been convicted of a crime other than a minor infraction or moving penalty?*

Yes
No

Preferred Form of Contact

Section 2 of 3:

The SAGE Program involves older adults who are over the age of 65 to participate as Senior Mentors. Are you currently age 65 or older?*

Yes
No

The program involves 4 visits over 1 year with your assigned students, either in-person or virtually, as determined by HSC on a semester-by-semester basis. Will this be acceptable for you?

Yes
No

Since the program provides practice for students in clinical skills, will you feel comfortable having the students ask personal details about your life?

Yes
No

Would you like to speak with someone about the program before you would decide to sign up?

Yes
No

Students reserve the right to file a report with the SAGE Administrative team should they feel their safety or the safety of their mentor is in jeopardy and/or requires additional assistance. Do you understand and agree to these terms?

Yes
No

Section 3 of 3:

CONSENT AUTHORIZATION AND AGREEMENT TO PARTICIPATE IN THE SAGE PROGRAM*

I agree to be a part of the program

PURPOSE

The purpose of Seniors Assisting in Geriatric Education (SAGE) Program is to help acquaint the osteopathic health care and inter-professional health professions’ students to a diverse population of older adults defined as those 65 years and up. It is our belief that this will help promote positive attitudes towards caring for older adults. All of the data obtained from this program will be collected for medical education evaluation and improvement. This is an education and training project created through funds received through the Reynolds Foundation and University of North Texas Health Science Center (UNTHSC), and is currently funded through UNTHSC and private donations. The SAGE Program is conducted by UNTHSC in partnership with Texas Christian University (TCU) and Meals on Wheels, Inc. (MOWI) of Tarrant County.

PROGRAM PROCEDURES

As an older adult assisting in the SAGE Program, you are volunteering to work with three to five health care professions’ students for the first two years of their healthcare education experience, as willing and able. It also means that you agree to meet with students assigned to you in your home. As a senior mentor, health care professions’ students will ask to perform a limited physical assessment on you, as well as ask to obtain some medical and personal information about you. These assessments are not meant for diagnostic purposes. You will also be asked to complete study questionnaires and provide constructive as well as personal comments to the students. The health care professions’ students are not doctors or licensed health care professionals and will not be providing medical advice. If you have any questions about your health, please contact your primary healthcare physician.

POTENTIAL RISKS

There are minimal risks from participating in this program. There is potential for embarrassment due to the assessments performed; however, you have the option of declining any questions/assessments or requesting that a same sex student is present. There is a minimal risk that a breach of confidentiality may occur in which program results may be accidentally revealed; however, all students have received HIPAA training prior to attending visits and program personnel will take all precautions necessary to protect your confidentiality, including removing your name from screening forms. Your health and personal information should remain confidential and should only be available to personnel overseeing the program. Information used for teaching or publication purposes should be kept strictly anonymous.

POTENTIAL BENEFITS

There are important benefits that participants may expect to gain by taking part in this program. The benefits may include: (1) Home safety evaluation; (2) Vital signs checks at every visit with information provided on a card to carry with you to your doctor; (3) Education on community resources; and (4) The analysis of the data collected from this program may provide a better insight in healthcare delivery among older adults.

CONTACTS

If you would like more information or have questions or concerns about the SAGE Program, please contact the UNTHSC Center for Geriatrics at (817) 735-0289 or SAGE@unthsc.edu. If you have any questions regarding the overall program evaluation part of this project, you may contact the Institutional Review Board, University of North Texas Health Science Center at Fort Worth at (817) 735-0409.

LEAVING THE PROGRAM

Your participation is completely voluntary. Should you decide not to participate, this will not be held against you in any way by UNTHSC, UNTHSC Health (if you are a patient), or any other agency used to recruit seniors for this program.

CONSENT

You agree to participate in the Seniors Assisting in Geriatric Education (SAGE) Program through UNTHSC. You understand your name will be checked with public records for criminal activity prior to participating in the program. The nature and purpose of your participation have been fully explained to you, and you have had the chance to ask any questions you have about the program. By agreeing to participate in the SAGE program and signing the consent below, you attest that all information provided in this application is truthful.

Senior Mentor Volunteer Application

Section 1 of 3: Personal Information

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Section 3 of 3:

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Senior Mentor Volunteer Application

Section 1 of 3: Personal Information

Section 2 of 3:

Section 3 of 3:

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