Peer Mentor Application Please complete this application to determine if you qualify to be a Peer Mentor to sleep apnea patients. Tell Us About You First Name Last Name Email Address Phone Number Zip Code Gender Year of Birth Time ZonePlease select… Eastern US Central US Mountain US Pacific US Hawaii/Alutian Alaska Daylight Time Outside of the US Are you a shift worker, who works nights regularly? YesNo Have you been using a PAP machine (CPAP, Auto PAP, Bilevel PAP) to treat your apnea for at least one (1) year?YesNo Please tell us why. reCAPTCHA helps prevent automated form spam. The submit button will be disabled until you complete the CAPTCHA. Contact Information Please complete this application to determine if you qualify to be a Peer Mentor to sleep apnea patients. Tell Us About You First Name Last Name Email Address Phone Number Zip Code Gender Year of Birth Time ZonePlease select… Eastern US Central US Mountain US Pacific US Hawaii/Alutian Alaska Daylight Time Outside of the US Are you a shift worker, who works nights regularly? YesNo Have you been using a PAP machine (CPAP, Auto PAP, Bilevel PAP) to treat your apnea for at least one (1) year?YesNo Please tell us why. reCAPTCHA helps prevent automated form spam. The submit button will be disabled until you complete the CAPTCHA. Contact Information
