Mentor ApplicationMentor Application First Name*Last Name*What is your current status in ACHE?*Student MemberMemberFellow (FACHE)RetiredLife Fellow (LFACHE)Address* City ZIP / Postal Code Phone*Email* What is your current title/position?*What organization do you work in?*Level of professional experience?*New Professional (<5 years)Mid-Level Professional (5-15 years)Senior-Level Professional (>15 years)Preferred method of meetings?* In person Phone Virtually AnyHow often would you like to be in contact with mentee?* Once every 2 weeks Once monthly Once quarterly As neededWould you be open to group mentoring?*Two mentors are matched with 3-5 mentees for group mentoring sessions.YesNoPlease attach a copy of your resume.*Accepted file types: pdf, doc, docx, Max. file size: 64 MB.Do you have additional preferences that you would like us to consider?DemographicsCollected for de-identified chapter reporting purposes.Age Group*<2525-3435-4445-5455-6465+Gender Identity*FemaleMaleIntersexPrefer not to answerRace*Select all that apply American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White or Caucasian Two or more races Prefer not to answerEthnicity*Hispanic or LatinoNot Hispanic or LatinoPrefer not to answerCAPTCHAΔ
