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2022 RBMA Leadership Mentoring Program - Mentee Application
Thank you for your interest in RBMA's Leadership Mentor Program. To be considered, please fill out the application below as thoroughly as possible. The application is due August 3, 2022
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1.
Full Name:
(Required.)
2.
Organization
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3.
Current Position:
(Required.)
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4.
Email:
(Required.)
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5.
Phone (Best number to reach you):
(Required.)
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6.
Please select your time zone
(Required.)
Central (CT)
Eastern (ET)
Mountain (MT)
Pacific (PT)
Other (please specify)
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7.
Share a short summary (30-50 words) of the work you perform at your organization:
(Required.)
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8.
Your educational background [include both formal (degrees) and informal (certificates, proficiencies)]:
(Required.)
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9.
What interests you in becoming a mentee?
(Required.)
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10.
What challenges would you like to resolve with your mentor?
(Required.)
Challenge 1
Challenge 2
Challenge 3
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11.
What are the three ideal characteristics of your mentor?
(Required.)
1
2
3
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12.
Specific areas of information that would be of most value to you:
(Required.)
Career guidance
Technical expertise in my field
Radiology culture, structure and relations
Leadership skills
Direction on taking the next step in my career
Managing a team
Increasing my financial/budget acumen
Other (describe)
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13.
Select your generation:
(Required.)
Boomer [1946-64]
Gen Xers [1965-1980]
Millennials [1980-1995]
Gen Z (1996-2012)
Other (please specify)
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14.
What is your race?
(Required.)
White or Caucasian
Black or African American
Hispanic or Latino
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Another race
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15.
Please select your age range
(Required.)
25-34
35-44
45-54
55-64
65+
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16.
Select your career stage
(Required.)
New CEO/Practice Leader
Early career, 1-5 years
Mid-Level Manager/Director, 6-10 years
Senior: 11 or more years
Other (please specify)
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17.
What is the ideal frequency of mentor/mentee check-in?
(Required.)
Twice a month
Monthly
Every other month
Quarterly
Other (please specify)
18.
To avoid pairing you with an individual who is your organization's competitor. Please list the top competitors for you and/or your organization.
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19.
To match you with a mentor that aligns with your professional and personal goals, please describe the professional strengths and areas for which you seek guidance and mentorship.
(Required.)
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20.
Where do you see yourself 5-10 years from now?
(Required.)
Current Progress,
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