Mentor program application

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

T.E.A.M Nurses

Email *

Name and credentials *

Phone number *

Address

Employer

Which application are you applying for? *

Mentor

Mentee

Briefly explain why would would like to be in the mentorship program. *

Please answer the following questions: *

Face to face

By phone

Web based

How do you prefer meetings?

When working in a group which is best for you?

For an initial meeting, which do you prefer?

Please answer the following questions: *

Yes

Maybe

Unsure

I work best alone

I work best in a group

I enjoy my current position

I would like to increase my knowledge

I can provide feedback to my peers

I can provide guidance to individuals

I can accept feedback and make corrections for things I may need to improve upon

I am good with meeting deadlines

I am good with motivating other individuals

I have good communication skills

Would you be able to attend the mandatory meetings? *

Yes

Unsure

Friday 11/1/19

Friday 11/6/2020

Commitment and Confidentiality

Being in the mentor program is a 10 month commitment. You agree that you will attend the required meetings and that you will have at least one monthly call with mentor/mentee. You agree that you will attend the yearly wrap up and may be asked to participate in a panel discussing the program. As a mentor you will receive free continuing education webinars available to you to complete prior to the end of the mentor program. You agree that you will be a member in good standing at time of application and for the duration of the program. You also agree to confidentiality of all things discussed during mentor meetings, with mentor/mentee and will provide a non-judgmental space for growth and learning.

By typing my name I agree to the commitment and confidentiality statement above.

YYYY

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms