UIC College of Nursing Alumni Mentor Program (AMP) Mentor & Mentee Enrollment Form

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 below questions in order to establish the best match possible.

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:

6. Preferred method of contact with mentor/mentee:

6. Preferred method of contact with mentor/mentee:

Please check all that apply:

 

Please check all that apply:

8. Your area(s) of expertise:

8. Your area(s) of expertise:

Please check all that apply:

 

 

 

13. In which role would you like to serve?

13. In which role would you like to serve?

For mentors only:

14. Are you open to serving as a mentor to more than one mentee?

14. Are you open to serving as a mentor to more than one mentee?

15. Would you prefer to mentor:

15. Would you prefer to mentor:

For mentees only:

16. Mentee relationship goal or desired outcomes:

16. Mentee relationship goal or desired outcomes:

For current AMP participants only:

18. 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 and continuing my mentor relationship with my current mentor/mentee

19. I'm interested in enrolling in AMP again but I would like a new mentor/mentee

19. I'm interested in enrolling in AMP again but I would like a new mentor/mentee

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