Mentor program application
T.E.A.M Nurses
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Email *
Name and credentials *
Phone number *
Which application are you applying for? *
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: *
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? *
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.
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