Mentee Application

First Name: *

Last Name: *

Place of Employment: *

Address of Employer: *

Current Nursing Position/Title and Years in the Position:

Work Phone: *

Email *

Mobile Phone: *

MOLN District: *

Enter required value District A District B District C District D District E District F District G

Number of Years as a Member of MOLN: *

Education: *

Number of Years of Nursing Experience: *

Which Best Describes You and Your Leadership Experience? *

Enter required value Early career and aspiring to a leadership role New to leadership and a strong desire to learn Looking at a next step for my career Experienced leader with specific needs for mentoring

If "Other" Please Explain:

Do You Have a Goal to be on the MOLN Board of Directors or Serve on a Committee? *

Enter required value Yes, Board Yes, Committee Maybe Not at this time

Career Goals: *

What are your career goals or areas of opportunity for professional development to focus on with your mentor?

Identify 2-3 Personal or Professional Goals: *

Identify 2-3 personal or professional goals for yourself. (These can be changed and formatted as SMART goals later.)

Where do you see Yourself in 3-5 years? *

What Attributes are you Looking for in a Mentor? *

This will assist us in matching you with the appropriate mentor.

Are you Willing and Able to Commit 1-2 Hours per Month to the Mentor Program and your Development? *

Mentor Match Preference: *

Enter required value I prefer to be matched within my heath system. I prefer a mentor from outside my organization. I do not have a preference.