Mentorship Registration Form

    What is the reason for your registration??

    Please make sure you fill the Checklist Form Below
    Your Information


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    Your Next of Kin

    I solemnly declare that I will abide by the aims and objectives of the Changing Disabilities as set out in the Organisations constitution and other duly adopted policy positions, that I am joining the Organisations voluntarily and without motives of material advantage or personal gain, that I agree to respect the Constitution and the structures and to work as a loyal member of the Organisations, that I will always strive to changing disabilities and help the organization to reach great heights.

    Mentorship Checklist Form

    • Consultants Information
    • About you
    • Family
    • Workplace
    • Life Interactions

    Consultants Information

    Last Name

    First Names

    Email Address

    Contact Number

    Where are you contacting us from?

    Who are you?

    Age, Gender and Race(Culture)

    Physical Barriers

    Medical History

    Family Illness

    Education

    Do you have a Family?

    Children and Ages

    Marital Status

    Sexual Life

    Extended Family

    Workplace Details

    Source of Income

    Designation

    Work Pressure

    Working Hours

    Social and Wellness

    Hobbys

    Entertainment

    Friends (Number)

    Confidants (Number)

    Religion

    Alcohol (Quantity in a Week)

    Smoking (Quantity in a Day)