Mentee Application Complete this application to be matched with an experienced mentor in oncology for career guidance and professional development. A program coordinator will contact you within 5 business days of submission. SECTION 1: Personal Information Question Title * 1. First Name Question Title * 2. Last Name Question Title * 3. Email Address Question Title * 4. Phone Number Question Title * 5. State Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont Other US State Outside US Question Title * 6. Are you a current NNECOS member? Yes No Comment: SECTION 2: Professional Background Question Title * 7. What is your profession? Physician Nurse/Nurse Practitioner Pharmacist Researcher Administrator Social Worker Physician Assistant/Associate Medical Student Resident Fellow Other (please specify) Question Title * 8. Current Role/Title Question Title * 9. How many years have you been working in oncology? 0-2 years 3-5 years 6-10 years 11-15 years 16+ years Question Title * 10. Institution/Organization Question Title * 11. Specialty Areas (Select all that apply) Medical Oncology Radiation Oncology Surgical Oncology Hematology Palliative Care Pediatric Oncology Oncology Nursing Clinical Research Health Administration Other (please specify) Question Title * 12. What is your primary practice setting? Academic Medical Center Community Hospital Private Practice Industry/Pharmaceutical Government/VA Non-profit Organization Other (please specify) Question Title * 13. Briefly describe your professional background and where you are in your career (3–5 sentences). SECTION 3: Mentorship Goals Question Title * 14. What stage are you at in your career? Student/Trainee Early Career (0-5 years) Mid-Career (6-15 years) Career Transition Question Title * 15. What are your primary mentorship goals? (Select all that apply) Clinical skill development Research guidance Leadership development Work-life balance Career transition advice Academic advancement Networking Publication guidance Grant writing support Other (please specify) Question Title * 16. Do you prefer a mentor located in your state? Yes No No preference Question Title * 17. Describe the specific challenges or questions you hope to address through mentorship Question Title * 18. What qualities are you looking for in an ideal mentor? SECTION 4: Communication Preferences Question Title * 19. What are your preferred communication methods? (Select all that apply) Video call (Zoom, Teams, etc.) Phone call In-person meetings Email Text/messaging Question Title * 20. How frequently would you like to meet with your mentor? Weekly Bi-weekly Monthly Flexible/as needed Question Title * 21. What is your preferred time commitment for this mentorship? 6 months 1 year Ongoing (flexible) SECTION 5: Additional Information Question Title * 22. Is there anything else you'd like us to know about your application? Question Title * 23. How did you hear about this program? Spring Meeting NNECOS Website Email/newsletter Colleague Referral Social Media Other (please specify) Program Terms and Conditions Agreement: I agree to the program terms and conditions, including maintaining confidentiality, committing to the minimum time requirements (1-2 contact points per month for a minimum of 6 months), and providing honest feedback for program improvement. I understand that my contact information will be kept confidential and only shared with matched mentors through the program coordinator. Question Title * 24. Type your full name below to indicate your acceptance of the program terms and conditions as stated above. Done
