Diverse Healthcare Leaders MENTOR Application

Diverse Healthcare Leaders MENTOR Application

Thank you for applying to be a mentor in the NCHF Diverse Healthcare Leaders Mentorship Program. Your expertise and willingness to share are invaluable to the success of the mentees and this program. Please complete all fields and we will be in touch regarding next steps.

Your Name

Current Title/Position

Employer/Organization Name

Street Address

City

State

Zip Code

Office/Work Phone Number

Mobile Phone Number

Email Address

Admin/Assistant Email Address

Best way to contact you?

Select or enter value

Race/Ethnicity

Select or enter value

Sex

Select or enter value

Professional Experience

Years of Healthcare Experience

Academic Degrees & Major

Are you a member of ACHE?

Select or enter value

Do you have previous experience as a mentor?

Select or enter value

Do you have a geographic preference?*

( ie, close proximity to my geographic location, only within my organization, etc.)

Are you willing to mentor more than one mentee?

Select

File Upload

Please attach the following documents: -CV/résumé -Personal Statement (less than 500 words)

Drag and drop files here or

I would like my email and phone number to be listed in the Mentorship Directory.

The Mentorship Program Directory connects program participants across cohorts. Please select this box if you would like to your contact information to be available to mentees and other mentors.

Disclaimer & Signature

I certify that the information given here is true and complete to the best of my knowledge. I authorize verification of all information in this application as it relates to the selection process.

Signature

Date

Send me a copy of my responses

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