GIC HIMSS Mentorship Application- Mentee

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.

Question Title

* 1. Please provide the following information:

Name

Company

Email Address

Phone Number

Question Title

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

Question Title

* 3. Years of HIMSS Membership

1-5 years

5-15 years

More than 15 years

Question Title

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

5-10 years

11-15 years

More than 15 years

Question Title

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

Leadership & Management

Project Management

Data Architecture

Informatics

Cybersecurity

Healthcare Analytics

Support & Experience Related to Current Position

Other (please specify)

GIC HIMSS Mentorship Application- Mentee

GIC HIMSS Mentorship Program 2021-
2022 Mentor Interest

Question Title

* 1. Please provide the following information:

Question Title

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

Question Title

* 3. Years of HIMSS Membership

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 9. Please upload a recent CV or Resume

GIC HIMSS Mentorship Application- Mentee

GIC HIMSS Mentorship Program 2021-2022 Mentor Interest

Question Title

* 1. Please provide the following information:

Question Title

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

Question Title

* 3. Years of HIMSS Membership

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 9. Please upload a recent CV or Resume

GIC HIMSS Mentorship Program 2021-
2022 Mentor Interest