Diverse Healthcare Leaders Mentorship ProgramMENTEE Application

Diverse Healthcare Leaders Mentorship Program

MENTEE Application

Thank you for your interest in applying to be a mentee in the NCHF Diverse Healthcare Leaders Mentorship Program. Please use the following form to provide us with information about your experience and interest in our program. All fields must be completed in order to be considered.

Personal Information

First Name*

Last Name*

Preferred Name

Gender Identity*

Select

Pronouns*

Select or enter value

Race/Ethnicity*

Select

Mailing Street Address*

City*

State*

Zip Code*

Contact Information

Please provide us with accurate phone numbers as well as the best way to reach you.

Mobile Phone Number*

Phone

Office/Work Phone Number

Phone

Work Email Address*

Application status will be sent via email to your work email

Preferred Contact Method*

Office/Work Phone

Mobile Phone

Professional Experience

Please provide us with accurate information on your professional experience in healthcare. We will use the information provided in this form and on your resume when reviewing your application.

Current Title/Position*

Employer/Organization Name*

Employer's Street Address*

City*

State*

Zip Code*

Years of Healthcare Experience*

Academic Degrees and Majors*

Document Upload*

Please attach the following documents:

CV/Resume
1 letter of recommendation; AND
Please provide a personal statement that is no more than 500 words.

Drag and drop files here or

Other Information

How did you hear about the program?*

For example, HR referral, Supervisor, Coworker, Website. Feel free to enter the name of the person.

Are you a member of ACHE?*

Select

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*

Please select the option below to receive a copy of your application.

Send me a copy of my responses

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