Affectus NSILP 2023 Mentoring Registration Form

Name*

First Last

Address - Street Name and Number OR PO Box*

City/Town*

Postcode

State*

Email*

Mobile*

Work Phone*

I am registering for Affectus NSILP 2023 Mentoring Program as a*

Mentor
Mentee

1. How would you rate your mentoring knowledge?*

Very high level mentoring knowledge
High level of mentoring knowledge
Some mentoring knowledge
Limited mentoring knowledge

2. How would you rate your mentoring experience?*

Very high level mentoring experience
High level of mentoring experience
Some mentoring experience
Limited mentoring experience

3. How would you rate your mentoring skills?*

Very high level mentoring skills
High level of mentoring skills
Some mentoring skills
Limited mentoring skills

4. What outcomes would you expect from the Affectus NSILP 2023 mentoring relationship?*

5. What are your career goals for the next 5 years?*

6. Do you have a personal vision or mission or purpose statement? Please share it with us.*

No more than 30 words

7. Provide three (3) BRIEF career highlights*

No more than 30 words

7. What is your greatest achievement?*

No more than 30 words

8. What are you passionate about?*

No more than 30 words

Consent - By entering your name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate to the best of your knowledge and that you are consenting that the information provided can be used for the purpose of the Affectus NSILP 2023 Mentoring Program and other activities connected to the Affectus NSILP 2023.*

Phone

This field is for validation purposes and should be left unchanged.

Affectus NSILP 2023 Mentoring

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