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* 1. What is your interest in the MSHIMA Mentorship Program?

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* 2. Full name

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* 3. Credentials

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* 4. Employer/organization

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* 5. Job title

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* 6. Student status

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* 7. City

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* 8. State

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* 10. Phone

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* 11. LinkedIn profile (optional)

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* 12. Years of HIM experience

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* 13. Areas of expertise (Select all that apply)

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* 14. Areas willing to mentor in (Select all that apply)

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* 15. Preferred mentee type

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* 16. Preferred communication method

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* 17. Preferred meeting frequency

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* 18. Time commitment available each month (in hours)

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* 19. Areas where mentorship is desired (Select all that apply)

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* 20. Agreement (Select all that apply)

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