Senior Mentor Program Volunteer Application

For questions about the Senior Mentor program, please contact Brenda Calhoun at 918-561-8211 or brenda.calhoun@okstate.edu.

General Application Information

Today's Date *

Mentorship Cycle *

Fall 2026 - Spring 2027

First Name *

Last Name *

Address *

Street address *Street address line 2

City *

State *

Postcode *

Country *

Home Phone

Cell Phone

Gender *

Date of Birth *

If other, please specify

Availability

Senior mentors will meet with their students three times each semester, for two semesters, in the mentor's home.

Are you willing to have students in your home? *

YesNo

Are you able to commit to both semesters? *

YesNo

Computer Experience

In the event we are unable to conduct in-home visits between students and mentors, visits will take place virtually over the computer (or smart phone or tablet) through Zoom, FaceTime, Google Meet, etc.

Please select all that apply:

I have a computer, tablet or smart phone capable of virtual meetingsI do not have a computer, tablet or smart phone capable of virtual meetingsI have used Zoom, FaceTime, or Google Meet beforeI have not used Zoom, FaceTime, or Google Meet

Comments

Special Considerations

If other, please specify

How did you hear about the senior mentor program?

Any additional information you would like to share?

Participation Agreement

Program Summary

You are invited to participate in the Senior Mentor Program, conducted by Oklahoma State University College of Osteopathic Medicine. In order to participate, you must be 65 years of age or older, in general good health and living independently.

The Senior Mentor Program is designed to help medical students become more competent, confident, and compassionate when working with older adults. Being a Senior Mentor means that you are volunteering to meet with a pair of medical students 3 times during the Fall semester of the students’ second year and 3 times during the Spring semester of the students’ second year of their medical school experience. The meetings will take place in the Senior Mentor’s home at a mutually agreed upon time between the Senior Mentor and medical student team. In the event we are unable to conduct in-home visits between students and mentors, visits will take place virtually over the computer, smart phone or tablet, utilizing Zoom, FaceTime, Google Meet, etc.

Assignments

During the 1-hour meetings you will be asked to assist your medical students in completing their assignments.

Voluntary Participation Agreement

Your voluntary participation will be an invaluable contribution to your medical students' education. There is no payment or any other means of compensation for participation in this program. This agreement can be ended at any time by the Senior Mentor or the faculty/staff of the Oklahoma State University College of Osteopathic Medicine Senior Mentor Program.

If you have additional questions about the Senior Mentor Program, please call us at (918) 561-8211. Thank you for participating in the Senior Mentor Program!

Agreement and Signature

The nature of my involvement has been explained to me and I agree to participate in the Senior Mentor Program. I will have the opportunity to participate in an orientation program and always have the opportunity to ask questions and/or reach out for support.

First Name *

Last Name *

Date *

By checking this box, I agree to participate in the Senior Mentor Program and accept the terms of this agreement. *

Emergency Contact Form

Today's Date *

Senior Mentor First Name *

Senior Mentor Last Name *

Emergency Contact First Name *

Emergency Contact Last Name *

Emergency Contact's Relationship to Senior Mentor *

Emergency Contact's Phone *

Comments

Please be sure that your emergency contact has a different phone number than yours!

Oklahoma State University Center for Health Sciences Contacts

Kelly Rudd, PharmD, BCPS, CACP, FCCP

kelly.rudd@okstate.edu

Office: 918-561-8239

Brenda Calhoun

brenda.calhoun@okstate.edu

Office: 918-561-8211

Photo Release Form

Photo/Video Release:

I hereby assign all rights of photography/video made of me related to the Senior Mentor Program at Oklahoma State University College of Osteopathic Medicine, and I hereby authorize the reproduction, exhibition and distribution of said photographs without limitation.

By checking this box, I agree to the terms of this photo/video release. *

Signature

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Phone *

Date *

Comments