Name(Required) First Last Email(Required) PhonePreferred method of contact(Required) Phone Email Date of Birth MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code What do you hope to gain from participating in the COATS program?(Required)Are there any specific topics you are interested in learning about during the didactic sessions? (ex: diet, exercise, etc. - these do not have to be health related)(Required)If you have participated in the program before, are there any specific topics that you feel are redundant and you would prefer we avoid talking about again?What are your hobbies/interests?(Required)Briefly describe your experience with healthcare professionals.(Required)Do you have any children or grandchildren? Yes No Where do your children/grandchildren live?Have you participated in COATS before and if so who was your mentee? Would you like to be paired with the same student this year?Do you have any preferences about the pairing process? Ex. I would prefer to be paired with a female/male mentee respectively.Are there any other things you would like to tell us?For example: I speak Spanish, I would love to be partnered with a student who also speaks Spanish, if possible. Δ
