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CATA Mentorship Program Sign-Up (Spring 2020)
The purpose of this program is to:

Purpose
1. To encourage “Established Professionals,” “Young Professionals” and Athletic Training Students to network with each other to build a stronger Athletic Training Community in the State of Connecticut.
2. To encourage “Young Professionals” and Athletic Training Students to gain a larger interest in the Athletic Training Profession and to encourage more involvement on the State/District/National Level.
3. To create networking opportunities for Mentorship Program Members at annual CATA Symposiums.

Mentor/Mentee applications will be accepted until March 30, 2020. Pairings will be announced no later than April 10, 2020 via an email to the participants. Please email cataypc@gmail.com with any questions.
First Name: *
Your answer
Last Name: *
Your answer
Age: *
Your answer
Email address: *
Your answer
Mobile phone number: *
Your answer
Number of years practicing as an athletic trainer *
Which University do you live or work closest to? *
Job setting *
Place of employment *
Your answer
Undergraduate school and Graduation Year *
Your answer
Graduate School and Graduation Year (If applicable) *
Your answer
NATA Number *
Your answer
CT License Number *
Your answer
BOC Certification Number *
Your answer
NPI Number
Your answer
Please describe your interest in joining the CATA YPC Mentorship Program *
Your answer
Please provide one goal you are hoping to achieve from your participation in the CATA YPC Mentorship Program. *
Your answer
Will you be available and able to communicate monthly with your mentor group? *
Have you ever received an disciplinary or corrective actions? *
If yes, please explain:
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Additional comments
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Please provide your initials as your eSignature *
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