CTAHE Mentorship Program - Mentee Application 2018

Mentee Application

Filling out this application assumes that you will be participating in a new mentor program where you will be

paired with an ACHE seasoned executive that is volunteering their time and commitment to your career

development. We look forward to recruiting engaged mentees who are motivated to learn through this program.

Please remember to provide your resume or CV to the membership development committee by emailing it to

eldridgeholly1202@gmail.com. This will be used to match you up with an appropriate mentee.

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* 1. Name:

Mr./Ms./Mrs./Dr./Other:

First Name:

Last Name:

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* 2. Contact Information:

Work Phone Number:

Cell Phone Number:

Home Phone Number:

Work E-mail:

Personal E-mail:

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* 3. Academic Degrees/Major(s):

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* 4. 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:

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* 5. List at least 3 skills and/or areas of knowledge that you feel you would like to improve upon. Why do you want to be a mentee? (Example: I would like to improve upon my communication skills, process improvement skills, contract negotiations, etc.)

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* 6. Describe 3 characteristics about yourself as a mentee. (Example: I work well with a mentor who will allow me to work by doing or be more hands on. OR I work well with a mentor who will provide me with resources to develop skills.)

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* 7. How far are you willing to travel to meet your mentor?

within 10 miles

within 25 miles

within 50 miles

Other (please specify)

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* 8.
Would you prefer to be matched with someone within your specific career field? (We will try our best to align you with an appropriate mentor, however, all of our mentors are well seasoned experts that will focus on career development.)

Yes, as best possible

No preference

Other (please specify)

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* 9. List any circumstances in which you don’t want to work with a particular mentor. (Example: I don’t want to be paired with someone within my organization.)

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* 1. Name:

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* 2. Contact Information:

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* 3. Academic Degrees/Major(s):

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* 4. Current Employment:

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* 5. List at least 3 skills and/or areas of knowledge that you feel you would like to improve upon. Why do you want to be a mentee? (Example: I would like to improve upon my communication skills, process improvement skills, contract negotiations, etc.)

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* 6. Describe 3 characteristics about yourself as a mentee. (Example: I work well with a mentor who will allow me to work by doing or be more hands on. OR I work well with a mentor who will provide me with resources to develop skills.)

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* 7. How far are you willing to travel to meet your mentor?

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* 8. Would you prefer to be matched with someone within your specific career field? (We will try our best to align you with an appropriate mentor, however, all of our mentors are well seasoned experts that will focus on career development.)

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* 9. List any circumstances in which you don’t want to work with a particular mentor. (Example: I don’t want to be paired with someone within my organization.)

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* 10. In 5 sentences or less, please describe your past work experience in healthcare.

* 8.
Would you prefer to be matched with someone within your specific career field? (We will try our best to align you with an appropriate mentor, however, all of our mentors are well seasoned experts that will focus on career development.)