ASA Mentor/Mentee Program Agreement
The American Society of Acupuncturists Acupuncture Mentor - Mentee Program Agreement
Sign in to Google to save your progress. Learn more
This agreement (“Agreement”) is by and between the person signing below and the American Society of Acupuncturists (“ASA”) as of the date set forth below. Please state whether you are a *
Required
Please provide the following information below: Name, Address, Phone Number, Email Address *
In order to be eligible to be a Mentor, the following requirements need to be met. By checking the boxes below, you are stating that the following statements are true and made in good faith. Please check all that apply.   *
Required
As a Mentor, what areas/topics do you feel most passionate about? Or, what topics would you like to teach? (Type N/A if you want to be a Mentee) *
As a Mentee, what areas/topics would you like to learn about? In addition, do you want a mentor from a specific state or areas of the country? (Type N/A if you want to be a Mentor) *
As a Mentor, what qualities would you like to see in a Mentee? (Type N/A if you want to be a Mentee) *
As a Mentee, what qualities would you like to see in a Mentor? (Type N/A if you want to be a Mentor) *
In order to be a Mentee, the following requirements need to be met if you have your own acupuncture practice. By checking the boxes below, you are stating that the following statements are true and made in good faith. Please check all that apply. *
Required
In order to be a Mentee, the following requirements need to be met if you are an acupuncture student. By checking the boxes below, you are stating that the following statements are true and made in good faith. Please check all that apply. *
Required
By signing below, I agree to allow the ASA to provide my name and contact information to one or more prospective individuals to serve as either a Mentor or Mentee to me.  The ASA attempts to match prospective Mentees with Mentors that go through a pre-screening application. The ASA makes no promise to successfully match any prospective Mentor or Mentee with another appropriate person. The ASA may elect to terminate a person’s participation in the ASA’s Mentor-Mentee Program (the “Program”) at any time.  The ASA may also alter, limit, or terminate the Program at any time with or without notice.  Accepting the above, I also agree to be bound by the terms and conditions set forth below: (Please check each box to acknowledge that have read each paragraph) *
Required
By typing your name and date below, I agree that I am eligible to participate in the ASA’s Program, and that I agree to the requirements set forth above including, without limitation, my obligations concerning the Guidelines attached as Exhibit A.  Exhibit A and ASA Guidelines are the Google documents that were sent to you with this form *
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