Ellen Perlman Simon Mentorship Program Application
City and State
Years Within Position
Years in Profession
I am applying to become a:
Please briefly describe why you want to become a Mentor/Mentee:
Please briefly describe what types of skills you would like to develop or guide others to develop as part of the Mentorship Program and what you hope to gain from this experience?
Please upload your current CV/Resume:
Please indicate which of the core program areas you wish to explore as the basis for a mentoring relationship:
Creating an Abstract
Performance Improvement Project
Have you had mentoring before?
Your Preference of Communication with your Mentor
By signing below, I confirm that the information provided in this application is true to the best of my knowledge and that I have read and understand the program description and its requirements. I understand that the submission of this application does not guarantee my participation in the SSWLHC Mentorship Program and, if accepted, I may be placed on a wait list based upon availability of resources at the time of application. I understand that this information will be shared with mentor application committee and my chosen mentor.I also hereby agree to hold harmless and indemnify the Society for Social Work Leadership in Health Care, its officers, agents and employees from any and all liability, loss, damages, costs or expenses which are sustained or incurred in connection with or in the course of the Mentorship Program.
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