{"id":8859,"date":"2026-04-10T17:13:08","date_gmt":"2026-04-10T17:13:08","guid":{"rendered":"https:\/\/prrf.org\/?page_id=8859"},"modified":"2026-04-18T03:00:33","modified_gmt":"2026-04-18T03:00:33","slug":"mentorship-program-connect-with-a-mentor-form","status":"publish","type":"page","link":"https:\/\/prrf.org\/ja\/mentorship-program-connect-with-a-mentor-form\/","title":{"rendered":"Mentorship Program: Connect with a Mentor FORM"},"content":{"rendered":"\n\t\t<div id=\"fws_69e3706f5de7e\"  data-column-margin=\"default\" data-midnight=\"dark\"  class=\"wpb_row vc_row-fluid vc_row\"  style=\"padding-top: 0px; padding-bottom: 0px; \"><div class=\"row-bg-wrap\" data-bg-animation=\"none\" data-bg-animation-delay=\"\" data-bg-overlay=\"false\"><div class=\"inner-wrap row-bg-layer\" ><div class=\"row-bg viewport-desktop\"  style=\"\"><\/div><\/div><\/div><div class=\"row_col_wrap_12 col span_12 dark left\">\n\t<div  class=\"vc_col-sm-12 wpb_column column_container vc_column_container col no-extra-padding inherit_tablet inherit_phone \"  data-padding-pos=\"all\" data-has-bg-color=\"false\" data-bg-color=\"\" data-bg-opacity=\"1\" data-animation=\"\" data-delay=\"0\" >\n\t\t<div class=\"vc_column-inner\" >\n\t\t\t<div class=\"wpb_wrapper\">\n\t\t\t\t<div class=\"nectar-split-heading  font_size_9vw \" data-align=\"default\" data-m-align=\"inherit\" data-text-effect=\"default\" data-animation-type=\"line-reveal-by-space\" data-animation-delay=\"0\" data-animation-offset=\"\" data-m-rm-animation=\"\" data-stagger=\"\" data-custom-font-size=\"true\" style=\"font-size: 9vw; line-height: 9.9vw;\"><h1 >Connect with a Mentor<\/h1><\/div>\n<div class=\"wpb_text_column wpb_content_element \" >\n\t<div class=\"wpb_wrapper\">\n\t\t<p>Requesting a mentor through the Stronger Together Mentor Program connects you with an individual or family that understands this journey in a way few others can.<\/p>\n<p>When you\u2019re adjusting to new information, new routines, and new questions, it can help to talk with someone who\u2019s already found their footing. A mentor offers a listening ear, shares real-life perspective, and provides steady encouragement as you move forward\u2014at your own pace.<\/p>\n<p>This isn\u2019t about having everything figured out. It\u2019s about having someone alongside you who understands the road ahead and is willing to walk it with you.<\/p>\n<p>You don\u2019t have to navigate this on your own\u2014connection can make all the difference.<\/p>\n<p><strong>Complete the application below and a PRRF team member will reach out within two business days.<\/strong><\/p>\n<p>Questions? Contact us at info@prrf.org.<\/p>\n\t<\/div>\n<\/div>\n\n\n\n<style id=\"wpforms-css-vars-8856\">\n\t\t\t\t#wpforms-8856 {\n\t\t\t\t--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-8856\"><form id=\"wpforms-form-8856\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"8856\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/ja\/wp-json\/wp\/v2\/pages\/8859\" data-token=\"28b4da699de6e1b7436ec55925a0d2e2\" data-token-time=\"1776513135\"><noscript class=\"wpforms-error-noscript\">\u3053\u306e\u30d5\u30a9\u30fc\u30e0\u306b\u5165\u529b\u3059\u308b\u306b\u306f\u3001\u30d6\u30e9\u30a6\u30b6\u30fc\u3067 JavaScript \u3092\u6709\u52b9\u306b\u3057\u3066\u304f\u3060\u3055\u3044\u3002<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">\u3053\u306e\u30d5\u30a9\u30fc\u30e0\u306b\u5165\u529b\u3059\u308b\u306b\u306f\u3001\u30d6\u30e9\u30a6\u30b6\u30fc\u3067 JavaScript \u3092\u6709\u52b9\u306b\u3057\u3066\u304f\u3060\u3055\u3044\u3002<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-8856-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><fieldset><legend class=\"wpforms-field-label\">Name <span 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for=\"wpforms-8856-field_5-postal\" class=\"wpforms-field-sublabel after\">\u90f5\u4fbf\u756a\u53f7<\/label><\/div><\/div><\/fieldset><\/div>\t\t<div id=\"wpforms-8856-field_12-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"12\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-8856-field_12\" >is or About<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-8856-field_12\" class=\"wpforms-field-medium\" name=\"wpforms[fields][12]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-8856-field_7-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-8856-field_7\">Age <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-8856-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>--- Select Choice ---<\/option><option value=\"I am 18 years of age or older\"  class=\"choice-1 depth-1\"  >I am 18 years of age or older<\/option><option value=\"I am UNDER 18 years old\"  class=\"choice-2 depth-1\"  >I am UNDER 18 years old<\/option><\/select><\/div><div id=\"wpforms-8856-field_8-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"8\"><h3 id=\"wpforms-8856-field_8\" aria-errormessage=\"wpforms-8856-field_8-error\">About your connection to rare retinal disease(s)<\/h3><\/div><div id=\"wpforms-8856-field_9-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-8856-field_9\">What rare retinal disease (or eye disease) do you or your family have experience with? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-8856-field_9\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-8856-field_9-error\" required><\/textarea><\/div><div id=\"wpforms-8856-field_10-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-8856-field_10\">What is your connection to the condition? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-8856-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>--- Select Choice ---<\/option><option value=\"Individual living with a condition\"  class=\"choice-1 depth-1\"  >Individual living with a condition<\/option><option value=\"Parent\/Guardian\"  class=\"choice-2 depth-1\"  >Parent\/Guardian<\/option><option value=\"Family member\"  class=\"choice-3 depth-1\"  >Family member<\/option><option value=\"Caregiver\"  class=\"choice-4 depth-1\"  >Caregiver<\/option><option value=\"Other\"  class=\"choice-5 depth-1\"  >Other<\/option><\/select><\/div><div id=\"wpforms-8856-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-8856-field_11\">How long have you or your family been living with the condition? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-8856-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-8856-field_11-error\" required><\/div><div id=\"wpforms-8856-field_14-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"14\"><h3 id=\"wpforms-8856-field_14\" aria-errormessage=\"wpforms-8856-field_14-error\">What You&#039;re Looking For<\/h3><\/div><div id=\"wpforms-8856-field_13-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"13\"><fieldset><legend class=\"wpforms-field-label\">Where do you feel you (or your family) are right now in your journey? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-8856-field_13\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-8856-field_13_1\" name=\"wpforms[fields][13][]\" value=\"Newly diagnosed\" aria-errormessage=\"wpforms-8856-field_13_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8856-field_13_1\">Newly diagnosed<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-8856-field_13_2\" name=\"wpforms[fields][13][]\" value=\"Adjusting\" aria-errormessage=\"wpforms-8856-field_13_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8856-field_13_2\">Adjusting<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-8856-field_13_3\" name=\"wpforms[fields][13][]\" value=\"Seeking resources\" aria-errormessage=\"wpforms-8856-field_13_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8856-field_13_3\">Seeking resources<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-8856-field_13_4\" name=\"wpforms[fields][13][]\" value=\"Looking for community\" aria-errormessage=\"wpforms-8856-field_13_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8856-field_13_4\">Looking for community<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-8856-field_13_5\" name=\"wpforms[fields][13][]\" value=\"Other\" aria-errormessage=\"wpforms-8856-field_13_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-8856-field_13_5\">Other<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-8856-field_3-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-8856-field_3\">What would a meaningful connection with a mentor look like for you? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-8856-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-8856-field_3-error\" required><\/textarea><\/div><div id=\"wpforms-8856-field_15-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"15\"><h3 id=\"wpforms-8856-field_15\" aria-errormessage=\"wpforms-8856-field_15-error\">Your Preferences<\/h3><\/div><div id=\"wpforms-8856-field_17-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-8856-field_17\">Would you prefer to be matched with someone who has experience with the same condition? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-8856-field_17\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][17]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>--- Select Choice ---<\/option><option value=\"Yes\"  class=\"choice-1 depth-1\"  >Yes<\/option><option value=\"No\"  class=\"choice-2 depth-1\"  >No<\/option><option value=\"No preference\"  class=\"choice-3 depth-1\"  >No preference<\/option><option value=\"Undecided\"  class=\"choice-4 depth-1\"  >Undecided<\/option><\/select><\/div><div id=\"wpforms-8856-field_18-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-8856-field_18\">Are there any preferences we should be aware of when matching you?<\/label><textarea id=\"wpforms-8856-field_18\" class=\"wpforms-field-medium\" name=\"wpforms[fields][18]\" aria-errormessage=\"wpforms-8856-field_18-error\" 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alt=\"\u8aad\u307f\u8fbc\u307f\u4e2d\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\n\t\t\t<\/div> \n\t\t<\/div>\n\t<\/div> \n<\/div><\/div>\n","protected":false},"excerpt":{"rendered":"Connect with a Mentor Requesting a mentor through the Stronger Together Mentor Program connects you with an individual or family that understands this journey 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