CTAHE Mentorship Program - Mentor Application 2018

Mentor Application

Hello! Thank you for becoming a mentor for the Connecticut Association of Healthcare Executives Mentorship Program! Please fill out this application and send your resume or CV to Holly Eldridge @ eldridgeholly1202@gmail.com. These two items will assist the committee members to pair a mentor with an appropriate mentee. You will be notified by the committee when the pairs will be matched.

Thank you for your commitment to the development of future healthcare leaders!

Sincerely,

The Membership Development Subcommittee of CTAHE.

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* 1. First Name:

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* 2. Last Name:

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* 3. Personal Title:

Mr.

Ms.

Mrs.

Dr.

Other

Other (please specify)

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* 4. Contact Information:

Primary Phone Number:

Primary E-mail:

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* 5. Academic Degrees / Major(s):

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* 6. Current Employment:

Name of organization:

Type of organization:

Address of current employer:

Current Position:

Years of Experience in your current position:

Years of Experience in healthcare administration overall (manager level and above):

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* 7. What are some skills, knowledge and experience that you feel are your strengths? Check all that apply.

Finance

Lean / Process Improvement

Six Sigma

Operations and Planning

Project Management

Data Analyst

Strategy / Strategic Planning

Human Resources

Leadership

Other (please specify)

CTAHE Mentorship Program - Mentor Application 2018

Mentor Application

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* 1. First Name:

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* 2. Last Name:

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* 3. Personal Title:

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* 4. Contact Information:

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* 5. Academic Degrees / Major(s):

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* 6. Current Employment:

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* 7. What are some skills, knowledge and experience that you feel are your strengths? Check all that apply.

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* 8. List any circumstances in which you would prefer not to serve as a mentor.

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* 9. What are some characteristics that you search for in a good mentee?

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* 10. What's your philosophy on being a mentor?