Mentee/Mentor Expression of Interest Form

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The Academy of Clinical Science and Laboratory Medicine Pilot Part II Mentoring Programme:

Following on from the success of the first Mentoring Programme, The Academy intends to pilot a second peer mentoring programme starting in June (estimated to run until October).

We are inviting Medical Scientist’s at all career stages and grades to express their interest in learning more about being a mentor and mentee by a fellow Academy member in the future, with regard to professional development. An expression of interest will not be considered a commitment to participate but will allow us to invite interested parties to information and training events.
Please Fill in the form below to indicate your preference about becoming a Mentee or Mentor for the upcoming Mentorship Programme.

Please note, training is provided (paid for by ACSLM) and the mentor/mentee will meet once or twice a month.

I am interested in taking part in the Mentoring Programme as a: *

Mentee

Mentor

Either Mentee or Mentor

Required

Name *

Employer (or most recent)/College *

Department/Speciality *

Position *

Phone Number *

Email Address *

ACSLM membership Number *

Mentee Application: Please provide a short account of the nature of the support that you would like to receive from a mentor: refer to https://acslm.ie/?page_id=7189 (ACSLM.ie then go to mentoring tab at top of page) for further detail

Mentor Application: Please provide a short account of the nature of the support that you feel you would like to offer potential mentees: refer to https://acslm.ie/?page_id=7189 (ACSLM.ie then go to mentoring tab at top of page) for further detail

Please tick this box if you consent to the data you have provided in this form being used by the ACSLM and EDelia (Mentor Programme Provider) solely for the purposes of the Mentor Programme. *

I agree

Required

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