GIC HIMSS Mentorship Program 2021-
2022 Mentor Interest

If you are interested in becoming a mentor, please complete the form below and include your CV or
resume with your response. If selected, you will be notified of the individual you will be mentoring by
the Professional Development Director. You must commit to providing guidance for the duration of
the mentorship program. Mentors 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 your areas of expertise?

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* 6. Please describe what you can provide to a mentee

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* 7. Please upload a recent CV or Resume

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