GIC HIMSS Mentorship Program 2021-
2022 Mentor Interest

If you are interested in becoming a mentee, please complete the form below. If selected, you
will be notified of the individual you will be a mentee by the Professional Development Director.
You must commit to providing guidance for the duration of the mentorship program. Mentees are
not obligated to continue the mentoring relationship past the program, but further
communication and connection is encouraged.

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* 1. Please provide the following information:

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* 2. What is your current position within your company?

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* 3. Years of HIMSS Membership

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* 4. Years of experience in Health Information Technology or Health Information Management

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* 5. What are you looking for in a mentor?

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* 6. Please share qualities, skills, and experiences you are looking for in a mentor.

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* 7. Why are you interested in the GIC HIMSS Mentorship Program?

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* 8. Please share any additional information that may support your mentor/mentee pairing.

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* 9. Please upload a recent CV or Resume

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