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AOHNA Registration Form Mentorship Program Registration Form
Prospective Mentors and Mentees please complete the questions below.
* Indicates required question
First and Last Name
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
Employer Name
*
Your answer
Position
*
Your answer
How long have you been an OHN?
*
Your answer
Areas of Expertise
*
Your answer
What motivated you to submit this application?
*
Your answer
Are you interested in being a mentor or mentee?
*
Mentor
Mentee
Both
Required
What do you hope to gain from this experience?
*
Your answer
Can you commit 1-2 hours a month for 12 months to connect with your mentoring partner?
***
Note that meeting format does not need to be face to face and can be another format (e.g. phone, Skype, Zoom etc.) as agreed on at the onset of the mentoring relationship.
*
Yes
No
Required
Please indicate your communication preference(s):
*
In Peron
Email
Text
Telephone
Video Conference
Required
If you are registering as a MENTEE please indicate what you are looking for in a Mentor.
Your answer
Please indicate the date you are submitting this application.
*
MM
/
DD
/
YYYY
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