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

Title*

Family Name*

First Name*

Postal Address inc postcode*

Mobile Phone*

Email Address*

Age*

Sex*

Female

Male

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

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

Have you ever had any restrictions placed on your Dental Board of Australia registration?*

Yes

If yes, please provide details:

What are your dental interests?*

What are your personal interests?

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

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

Are you a member of your local division/study group branch?*

Yes

If not, would you like to join your local division/study group?

Yes

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

By submitting this form you are expressing an interest to become part of the ADAPTS Mentoring Program.

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