PONL Mentorship - Mentee Application

PONL Nurse Leader Mentorship Program: Mentee Participation Form
Make this the year you level up! Connect with a mentor to help you achieve your career and personal goals. There is no cost for PONL members - this is a value of your membership. The time commitment is approximately 1 hour per month for 6 months.

Please see some of the tools and guidelines developed to help you understand the commitment and process:

Mentorship Program Guidelines

Mentorship Program FAQ

Mentor-Mentee Matching Process

Mentee Development Form

Once your application is submitted, it will be reviewed by the committee for eligibility. We will be in touch to advise you of the next step in the process. We look forward to working with you.

As always, if you have any questions, please do not hesitate to contact Tricia at the PONL Office.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date available to start as a mentee*

MonthDayYear
Date
Current position/Title*
Organization/Employer*
Please upload your current CV/Resume*

Cancelof
Please upload your current headshot to be used on the Mentorship page of the PONL website*

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Career Background and Experience.

Please check the categories that apply to you:
Level of Responsibility*

Vice PresidentCNODirectorManagerEducatorSupervisorAPRNCharge NurseOther
Type of Organization*

Hospital/Medical CenterHealthcare System LevelAmbulatory Care Facility/ClinicAcademiaBehavioral HealthLong Term Extended CareHome HealthHospiceGovernment/PolicyOther
Number of Years in Leadership/Management Roles:*
Please select the degrees you hold*

AsociatesBSNMAMSNMBAMPHDNPPhDOther
Please select the certifications you hold*

CENPCLNMCNENEA-BCNE-BCOther
Areas of Interest and Need
Please list your area(s) in which you are seeking to gain additional knowledge, development, and competence below:*
Nurse Leader Competencies: Communication and Relationship Building: Please select those areas of most interest and need for development below.*

Academic relationshipsCommunity involvementDiversity, Equity and InclusionEffective communicationInfluencing behaviorsMedical staff relationshipsNetworkingRelationship management
Nurse Leader Competencies: Knowledge of the Health Care Environment: Please select those areas of most interest and need for development below.*

Advocacy/health care policyCare managementClinical practice knowledgeDelivery models/work designEvidence-based practice/outcome measurementHealth care economicsInformaticsTechnology/AIPatient safety/Quality improvement/metrics/risk managementPopulation HealthRegulations and Compliance
Nurse Leader Competencies: Leadership and Professionalism: Please select those areas of most interest and need for development below.*

Systems and complex thinkingChange managementDecision makingTransformation and innovationProfessional accountabilityOrganizational accountabilityGovernanceEarly Career PlanningC-Suite Career Planning
Nurse Leader Competencies: Business Skills: Please select those areas of most interest and need for development below.*

Financial and business managementStrategic planning and managementHuman resources managementInformation technology and managementPerformance improvement and excellence
Reason for Mentorship
Please write a paragraph as to why you are seeking mentorship and what goals you would like to accomplish in the mentorship process.
Commitment Statement

By signing below, I understand that participation as a mentee in the Nurse Leader Mentorship Program involves regular engagement and goal-setting during the designated program period. I agree to maintain professionalism, confidentiality, and accountability throughout the mentoring relationship.
Signature*

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PONL Nurse Leader Mentorship Program: Mentee Participation Form

Career Background and Experience.

Areas of Interest and Need

Reason for Mentorship