[ Application for Mentees _ English ]

Dear Candidate,

By this survey, we are collecting your data to become a mentee in the WFSA. Applications for this edition will be open from 10 April to 10 May 2024.

Before filling in this application form, please note that the minimum duration of this programme will be one year, from the beginning to the end of the mentorship programme. Be sure to fill in the application form in the language you would prefer to use for your mentoring (English, French or Spanish).

If you have any problems filling out this survey, please contact us by email at: mentorship@wfsahq.org

Thank you for your time and interest,

WFSA Secretariat

Question Title

* 1. Title

Question Title

* 2. First Name

Question Title

* 3. Surname

Question Title

* 4. Email

Question Title

* 5. Telephone (please, add your country code)

Question Title

* 6. Date of birth (day/month/year)

Question Title

* 7. Gender

Question Title

* 8. Nationality

Question Title

* 9. Country where you work

Question Title

* 10. City and Country of your institution

Question Title

* 11. Current working position

Question Title

* 12. Current Career Level

Question Title

* 13. Year you obtained your medical degree

Question Title

* 14. Year in which you obtained your speciality degree in Anaesthesiology

Question Title

* 15. Area of specialization in Anaesthesiology

Question Title

* 16. Years of experience in your area of specialisation in anaesthesiology

Question Title

* 17. Name of the National Society of Anaesthesia you are affiliated to

Question Title

* 18. Why you would want to be part of this Mentoring Programme? (maximum 200 words)

Question Title

* 19. What are your areas of clinical and academic interest? Clinical, Career development, or Leadership (Please, choose one and add any comment If needed)

Question Title

* 20. In case you have chosen the Clinical Area, please choose one of these categories:

Question Title

* 21. Goals you would like to achieve in your relationship with a mentor (maximum 200 words)

Question Title

* 22. Professional / career goals or ambitions (maximum 200 words)

Question Title

* 23. Areas you would like to develop

Question Title

* 24. Planned duration of your mentoring programme

Question Title

* 25. ‘Be my mentor’

[ On this option, mentees can suggest a specific mentor. If this option is chosen, WFSA will contact the proposed mentor and try to have them in our programme. An additional short letter of motivation from the prospective mentee will be required for this. If, for any reason, the suggested mentor is unable to participate, we will assign another mentor from those who have applied ]

Question Title

* 26. Languages you speak

Question Title

* 27. Languages you write

Question Title

* 28. Preferred language(s) of communication

Question Title

* 29. Short biography (maximum 200 words)

Question Title

* 30. Please upload your CV here

PDF, DOC, DOCX file types only.
Choose File

Question Title

* 31. Please, upload here the Proof of Membership to your National Society of Anaesthesiologists (which must be a Member of the WFSA)

(*** Important: Please note that incorrect documentation might delay your application)

PDF, DOC, DOCX file types only.
Choose File

Question Title

* 32. I agree to the following points:

T