2022-23 UIC College of Nursing Alumni Mentor Program (AMP) | Mentor & Mentee Enrollment Form

Thank you for your interest in serving as a mentor or mentee! Please fill out all of the questions below in order to establish the best match possible. The more details you provide, the better. 

Current AMP participants: we ask that you scroll down to questions 18 & 19. If you wish to continue with your current mentor or mentee, please indicate if so. This helps us keep track of current participants. If you'd like a new match (#19), please fill out the rest of the form as that helps with the best pairing. 

If you experience any difficulties with this form, please contact Sara Almassian at salmas1@uic.edu.

 

 

Please check all that apply:

3. UIC Nursing campus:

3. UIC Nursing campus:

Please check all that apply:

Please list preferred email for contact with mentor/mentee:

Please list preferred email for contact with mentor/mentee:

 

Please list preferred phone for contact with mentor/mentee:

Please list preferred phone for contact with mentor/mentee:

 

 

Please check all that apply:

7. Your area(s) of expertise OR for early career nurses, your area(s) of interest:

7. Your area(s) of expertise OR for early career nurses, your area(s) of interest:

Please check all that apply:

8. If you selected Clinical Practice above, please specify your practice area(s):

 

 
12. In which role would you like to serve?

For mentors only:

13. Are you open to serving as a mentor to more than one mentee?
14. Would you prefer to mentor:

For mentees only:

15. Mentee relationship goal or desired outcomes:

15. Mentee relationship goal or desired outcomes:

For current AMP participants only:

17. I'm interested in enrolling in AMP again and continuing my mentor relationship with my current mentor/mentee
18. I'm interested in enrolling in AMP again but I would like a new mentor/mentee

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