Mentorship Application

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Submit Date

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Type Parameter

Name(Required)

First Middle Last

Email Address(Required)

Phone(Required)

LinkedIn Address(Required)

Are you an NC HIMSS Member?(Required)

Yes

Organization(Required)

Title(Required)

Briefly describe your career background and or future goals and objectives:(Required)

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In what areas are you looking to expand your knowledge? (i.e. communication or presentation skills, conflict resolution, etc.)(Required)

What areas of Healthcare IT interest you most and/or would you like to learn more about? (i.e. cybersecurity, informatics, AI, etc.)(Required)

What is your availability to meet with your mentor?(Required)

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Briefly describe any previous experience you have of being a mentor:(Required)

Briefly share why you want to be a mentor to others in the healthcare IT industry:(Required)

What areas of Healthcare IT interest you most? (i.e. cybersecurity, informatics, AI, etc.)(Required)

What is your availability to meet with your mentee?(Required)

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What is your preferred method(s) of communication?(Required)

This will be used for meeting coordination.

Online (Teams/Zoom, etc.)

In Person

Both

How did you hear about this mentorship program?(Required)

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