Mentor Application Join our mentorship program to guide the next generation of oncology professionals. Share your expertise and help shape careers in oncology. 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 Other (please specify) Question Title * 8. Current Role/Title Question Title * 9. How many years have you been working in oncology? 3-4 years 5-7 years 8-10 years 11-15 years 16-20 years 21+ 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. Please upload your current CV SECTION 3: Mentorship Expertise Question Title * 14. What are your areas of expertise that you can share with mentees? (Select all that apply) Clinical practice excellence Research methodology Grant writing Leadership/management Academic career development Private practice transition Work-life integration Publication/writing Clinical trials Patient advocacy Other (please specify) Question Title * 15. What is your career focus? (Select all that apply) Clinical Practice Academic Medicine Research Administration/Leadership Industry Patient Advocacy Education/Teaching Other (please specify) Question Title * 16. Do you have a geographic preference for your mentor? Yes, I prefer a mentor within my state or region Yes, I prefer a mentor outside my state or region No Preference — Either is fine Question Title * 17. Describe any previous mentorship experience you have (formal or informal) Question Title * 18. What specific topics or disease areas do you feel most qualified to mentor in? 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 are you available to meet with a mentee? Weekly Bi-weekly Monthly Flexible/as needed Question Title * 21. What is your preferred time commitment for mentorship? 6 months minimum 1 year minimum Ongoing (flexible) SECTION 5: Additional Information Question Title * 22. Is there anything else you'd like us to know about your mentorship style or availability? 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 mentees 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
