SPEED MENTORING AT PHM 2018

Sunday, July 22nd
7:00 - 8:30 AM

Mentor Registration Form

* Required Fields


1. General information

*First Name
*Last Name
*Email
*Organization
*Title
*Cell Phone (for on-site communication)

2. Are you an APA member?

Yes
No

*3. Please select your top three choices as a mentor with 1 = highest and 3 = lowest.

Advocacy, Policy and Public Health 1. 2. 3.
Research in PHM 1. 2. 3.
Career Development and Transition 1. 2. 3.
Leadership Skills 1. 2. 3.
Community-Engagement 1. 2. 3.
Quality Improvement 1. 2. 3.
Educational Scholarships/Teaching Skills Development 1. 2. 3.
Work-Life Balance 1. 2. 3.

4. Facilitator responsibilities include moving the conversation forward and obtaining goal cards from each mentee. Additionally, sending an email to each mentee 3 months later reminding them of their goals. Are you willing to be a facilitator?

Yes
No

*5. Please upload your CV.


The APA Board has made a commitment to increasing diversity and inclusiveness in all of our venues. In that spirit, the Speed Mentoring Committee would appreciate your telling us:

6. Do you identify as an under-represented minority?

Yes
No

7. Please note your ethnicity:


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