Women in Healthcare Mentorship Program Questionnaire

Thank you for your interest in the Women In Healthcare Mentorship Program. The WIH Mentorship Program is a four to six 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:
This application form will be available online until March 31, after which the Mentorship Committee will begin the pairing process. You will receive an update from the committee by early April, and WIH will host a Mentorship Kick-Off event in mid to late April.

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

Question Title

* 1. Participant Information:

Name:

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