2019 USRC Mentee Application
Home Residence City
How many years as an RT?
Current Work Facility
Current Job Title
Briefly describe your career, including types of positions held and length of service.
In which of the following areas would you like to be mentored? Choose up to 3.
Adult Acute Care
Long Term Acute Care/Subacute Care
Pulmonary Function Testing
Peer Mentor (student or RRT < 5 years)
Please put the three areas you chose in order of importance
What is your preferred method(s) of interaction with your mentor (email, phone, skype, in-person, etc.)?
What do you hope to achieve by participating in this program?
What are your short-term (1-3 years) goals?
What are your long-term (3-5 years) goals?
What are some criteria by which you would want to be matched with a mentor?
Do you care about gender when making your mentor match?
If you answered yes to the question above, what gender do you prefer your mentor to be?
By electronically signing below, I agree to commit at least one hour per month with my mentor and working towards completing my goals/objectives.
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