ADANSW Mentor Application Form
Note: In order to participate in the Australian Dental Association (NSW Branch) Professional Transitional Support Program (ADAPTS) you must be a current ADA NSW Member.
SECTION 1: PERSONAL DETAILS
SECTION 1: PERSONAL DETAILS
Title
*
Family Name
*
First Name
*
Postal Address inc postcode
*
Mobile Phone
*
Email Address
*
Age
*
Sex
*
Female
Male
SECTION 2: EDUCATION AND REGISTRATION DETAILS
SECTION 2: EDUCATION AND REGISTRATION DETAILS
Graduation Year
*
University Attended
*
Qualifications
*
Specialisations
*
Year Commenced Registration with Dental Board
*
Year Commenced Membership with ADANSW
*
SECTION 3: EMPLOYMENT DETAILS
SECTION 3: EMPLOYMENT DETAILS
Position
*
Practice Name
*
Practice address
*
Previous Work Experience: (include: Employer, Position Held, Dates of Work)
*
Referee 1 - Name & Phone No:
*
Referee 2 - Name & Phone No:
*
SECTION 4: ADDITIONAL INFORMATION
SECTION 4: ADDITIONAL INFORMATION
Have you ever had any restrictions placed on your Dental Board of Australia registration?
*
Yes
No
If yes, please provide details:
What are your dental interests?
*
What are your personal interests?
SECTION 5: MENTORING DETAILS
SECTION 5: MENTORING DETAILS
What are your objectives for participating in the ADAPTS Mentoring Program?
*
What qualities can you offer as a Mentor?
*
Please provide details of any previous Mentoring Experience?
*
SECTION 6: PROGRAM REQUIREMENTS
SECTION 6: PROGRAM REQUIREMENTS
Would you prefer your mentee to be
*
Female
Male
Either
Are you willing to participate in distance mentoring (e.g. where you cannot easily meet face-to-face with your mentor on a regular basis)?
*
Yes
No
Are you a member of your local division/study group branch?
*
Yes
No
If not, would you like to join your local division/study group?
Yes
No
Are you able to attend the Mentoring Induction Session in February 2016, a minimum of three mentoring sessions throughout the year and an end of program evaluation session in February 2017?
*
Yes
No
By submitting this form you are expressing an interest to become part of the ADAPTS Mentoring Program.
By submitting this form you are expressing an interest to become part of the ADAPTS Mentoring Program.
*
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