Maryland Chapter Women in Healthcare Mentorship Program Questionnaire

Thank you for your interest in the Women In Healthcare Mentorship Program. The WIH Mentorship Program is an eight month engagement where mentors and mentees are encouraged to connect monthly to discuss mentees' goals. Each pair is supported by the WIH chapter leadership team with resources and advice to support your engagement.

Program Timeline:
Please complete this application by March 6th, after which the Mentorship Committee will begin the pairing process. You will receive an update from the committee regarding the Mentorship Kick-Off event.

Thank you for your interest and we look forward to supporting your goals!

Question Title

* 1. Participant Information:

Name:

Women in Healthcare Chapter Affiliation:

Professional Credentials (if applicable):

Employer Name:

Job Title:

Primary Role:

Work Address:

City:

State:

Zip:

Phone (Home):

Phone (Cell)/Ext:

Email (Work):

Email (Home)

Other Associations you are a part of, (career or personal):

Question Title

* 2. Please Express your interest:

I want to be a Mentor

I want to be a Mentee

I want to be a Mentor and a Mentee