ACHE-SETC Mentorship Application
Application for:
Mentor
Mentee
Both
Name
*
First Name
Last Name
Title
Department
Employer
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Preferred Method of Communication
*
Email
Phone
1. If a mentor, what aspects of the current healthcare environment are you most involved in/have the most interest? If a mentee, what aspects of the current healthcare environment are you most interested in? (Please rank top 3).
Alternative Care
Long Term Care
Ambulatory Care
Managed care
Behavioral Health
Logistics
Business Development
Mergers/Acquisitions
Corporate Compliance
Operations
Finance
Information Systems
Physician Practices
For-Profit
Quality Assurance
Human Resources
Strategic Planning
Marketing
Other
2. What is your current membership status in the American College of Healthcare Executives?
Member
Fellow (FACHE)
Student Associate
3. How many years of Healthcare Management experience do you have?
Under 5 years
6-8 years
8-11 years
11-15 years
15+ years
4. Please list academic degrees and school(s) attending
5. Have you been a mentor/mentee before?
No
Yes, please describe
6. If a mentor, please indicated the number of mentees you would be interested in mentoring at any given point during the year.
1
2
7. If a Mentee, very briefly, what are your career goals?
8. Please provide any other information you feel would be important, such as past mentorships, internships.
9. If currently enrolled in a university program, please attach a Statement of Commitment, Program Coordinator’s/Program Director’s Written Endorsement, and updated resume with the application. If you do not have this information readily available, please email it to achesetcmentorship@gmail.com
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