Careers in Geriatrics Local Mentoring Program Local Mentor Request Form

Name:

Affiliation:

Mailing Address:

Street:
Apt./Suite:
City:
State:
Zip Code:
Telephone:
Ext:
Fax:
Email:

1. Please describe your career goals over the next 5 years.
   
   
   
2. Please indicate below what you are leaning towards as a primary career.
   Medicine
   Nursing
   Pharmacy
   Social Work
   Other, please specify
   
   
   
3. Please write a short description (3 to 5 sentences), detailing your reasons for participating in the Careers in Geriatrics Local Mentoring Program and what you hope to get out of the program.
   
   
   
4. How involved would you like your mentor be? How much time would you like to spend with your mentor (i.e., one time contact, ongoing contact)
   
   
   
5. What is the best way to communicate with your mentor?
   Telephone
   Email
   In Person
   
   
   
6. Is there anything else that you want to tell us that would help us match you with a Mentor?