1.Contact details
Name
Address
Phone (work) (home)
Mobile
Fax
Email
Which is your preferred method and time of contact?
………………………………………………………………………………………
2. Areas of expertise/ interest (please list)
3.Mentoring experience
Have you had a mentor before ? Y / N
Have you been a mentor before? Y / N
Have you ever participated in mentor training? Y / N
Please note your response to question 3 is to assist us to determine
information needs it will not be released .
4.Profile
(please write a statement that can be made available to potential
mentees. Include information such has your current position and
responsibilities, qualifications, experience, involvement in professional
activities, what you would like to get out of being a mentor and
anything else you feel is relevant)
5.Permission
I ………………………………………………(please
print clearly)
give permission for the information I have provided on the Mentor
Expression of Interest form (with the exception of my response to
Q3) to be made available by the College of Nurses, Aotearoa (NZ)
to nurses seeking a Mentor.
I understand that at any time I can withdraw my
interest by writing or emailing the College of Nurses Aotearoa(NZ)
Administrator.
………………………………………………
……………………………….
Signature Date
