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Mentor Application
1.
What is your name?
2.
What is your email?
*
3.
In what city are you located?
(Required.)
*
4.
Which degree(s) do you hold?
(Required.)
High School Diploma or Equivilent
Associate's
Bachelor's
Master’s
Graduate (PhD, JD etc.)
Certification(s) only
Which degrees:
5.
What industry certifications do you currently hold?
*
6.
What is your career level?
(Required.)
Medical (RN, MD/DO, PA etc.)
Education (Professor, Teacher)
Leadership (C-Suite Level, Director, Manager)
Other (please specify)
*
7.
What is your educational or professional background/expertise?
(Required.)
Cybersecurity or Information Technology (IT)
Data & Analytics or Informatics
Engineering
Medical
Health Information Technology (HIT)
Healthcare
Other (please specify)
*
8.
How many years of professional experience do you have?
(Required.)
1 – 2 years
3 – 5 years
5+ years
*
9.
What is your availability to meet with your mentee? Choose all that apply.
(Required.)
Monthly
Biweekly
Weekly
*
10.
Are you open to being matched with more than one mentee?
(Required.)
Yes
No
If yes, how many max?
*
11.
What are your goals from this program as a mentor?
(Required.)
*
12.
What type of mentorship would you like to provide to your mentee?
(Required.)
*
13.
What are your expectations of the mentee and the program experience?
(Required.)
