Mentorship Pilot Program - Application

The Mentorship Pilot Program has been designed to allow practitioners to improve their professional competency and leadership skills through the identification of areas of development and continued growth in areas of personal strength and organizational leadership. Once demonstrated to be effective, the scope of the program is expected to expand in volume and scope. The pilot will be 6 months in length. Five mentees will be chosen for the pilot program.

Timeline:

Mentee application October 2018. Deadline January 10, 2019
Mentee/mentor match February 2019
Pre-Survey completion February 2019
Orientation Webinar for mentees/mentors March 2019
Pilot program launch at Annual Conference April 3-6, 2019 with meet and greet meeting, if in attendance
Pilot program start 6 month from April 8-Oct 9, 2019
Midpoint evaluation and Conference call July 2019
Practice Management 2019 program attendance
Post Survey/Feedback October 2019

All application materials must be received by January 10, 2019. Since candidates are required to obtain recommendation letters from third parties, they are encouraged to start the application process early to ensure timely receipt of all materials.

Question Title

* Address

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Preferred Email Address

Preferred Phone Number

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* Please upload your CV in one of the following formats: .pdf, .doc, .docx.

PDF, DOCX, DOC file types only.

Choose File

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* Please prepare a Candidate Statement of 750 words or less and upload the file using the "Choose File" button below. The Candidate Statement should provide details on:

Leadership positions, roles and/or skills.

Professional goals (one of the stated goals must be to serve HOPA in a leadership capacity).

Your Leadership/vision philosophy, and how have you exemplified these qualities in your work and/or community.

Why you want to participate in this pilot program.

Upload the statement in one of the following formats: .pdf, .doc, or .docx.

PDF, DOCX, DOC file types only.

Choose File

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* Please initial the following boxes as an agreement to participate in this program.
I express my willingness to:

participate in training that will include background reading and orientation webinar

meet at least monthly with the assigned mentor

join mentor in HOPA activities that the mentor is involved with

attend other meetings / calls as deemed necessary by the HOPA Board, or the Leadership Subcommittee

document all interactions, complete pre/post survey and provide a summary report evaluation with constructive feedback to improve and expand the program

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* By entering your name and date below, you are electronically signing this agreement. You agree your electronic signature is the legal equivalent of your manual signature and certify that all of the information provided is true.

Full Name

Date

If you have any questions about this process, please contact Sarah Tiwana at stiwana@hoparx.org. All materials must be submitted by 11:59 pm on January 10, 2019. Once finished with the application, please click on the "Submit" button below.

Question Title

* Address

Question Title

* Please upload your CV in one of the following formats: .pdf, .doc, .docx.

Question Title

Question Title

* Please initial the following boxes as an agreement to participate in this program. I express my willingness to:

Question Title

* By entering your name and date below, you are electronically signing this agreement. You agree your electronic signature is the legal equivalent of your manual signature and certify that all of the information provided is true.

* Please initial the following boxes as an agreement to participate in this program.
I express my willingness to: