CSIH MentorNet - Application form for Mentors (2017 Program Year)
Thank you for your interest in MentorNet, a unique program that connects students and young professionals (SYPs) interested in global health with experts experienced in the field.

We are excited that you are interested in becoming a mentor for our program!

Please fill in this brief form to help us understand your interests in global health and mentoring style and preferences.

Deadline to submit your application is 11:59 EDT Thursday, October 20th, 2016.

If you have any questions, please feel free to email us at csih.mentornet@gmail.com or visit us at https://csihmentornet.wordpress.com/
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Basic Information
Title
First Name *
Last Name *
Organization/Institution *
Work Title *
Department
Mailing Address/Place of residence *
Primary phone number *
Email *
LinkedIn Profile (optional)
Please paste the link to your profile below.
Preferred language of correspondence *
Required
Background Information
Education: *
Past positions held: *
Previous experience mentoring: *
This may be formal or informal.
Area(s) of Global Health interest or expertise (in research, education, or career): *
(Please select all that apply)
Required
From the list above, please rank the top 5 areas you are most interested in in the space below:
You may also wish to provide more information about specific geographic areas (e.g., Sub-Saharan Africa, Latin America) and sub-topics of interest (e.g., malaria, TB, immunization, water and sanitation)
Why do you want to be a mentor in the CSIH’s MentorNet program? *
Please list THREE topics/areas of interest you would you like your SYP to have knowledge/experience in and provide a brief description why. *
You may include: course of study, topic area, geographic region, skills etc. We endeavour to match SYPs and mentors as effectively as we can, so please provide us with any information that may help us match you with a suitable SYP.
What do you hope to be able to offer to a Student or Young Professional (SYP) through your mentorship? *
Please describe your mentorship philosophy and present ideas on how you hope to support the SYP in achieving their learning objectives.
Please describe how you think participating in this program as a mentor will benefit you personally/professionally?
In less than 300 words, please describe the professional experience(s) that have been the most influential in defining your global health interests and career aspirations?
You may wish to include paid, volunteer, internship, or research engagements
Preferred method (s) of communication with SYP: *
Required
How often do you anticipate you will be able to correspond with your SYP? *
Consider your time commitments for 2017.
Realistically, how much time can you spend per month corresponding with your mentee (i.e. through email correspondence, Skype/Google Hangout calls, or in-person meetings)? *
Consider your time commitments for 2017.
 Is there anything else that you would like to share with us regarding your suitability/candidacy for the program?
Videos, pictures, blogs, essays that give us more information on "who you are and how you fit into the world of global health" are welcome.
How did you hear about the CSIH MentorNet program? *
Can you recommend a colleague who you think may be interested in being a mentor for MentorNet or would like to learn more about the program?
*If you are not comfortable providing their contact information, please feel free to forward them the link to this application form or have them email csih.mentornet@gmail.com for more information
By submitting this form, you agree to: *
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