Academic Health Department Mentor Form

Thank you for your interest in serving as a mentor for the Academic Health Department (AHD) Mentorship Program. An activity of the AHD Learning Community, the AHD Mentorship Program aims to foster the development, maintenance, and expansion of AHDs by building ongoing mentoring relationships between individuals involved in AHD efforts.

To volunteer as an AHD mentor, please provide the following information about yourself and your AHD experience/expertise. This information will be shared publicly on the AHD Learning Community website and used in matching mentors and mentees. If you have any questions or would like additional information, please contact Kathleen Amos at kamos@phf.org.

Question Title

Contact Information

Name (Required): *

Degree(s)/Certification(s):

Title(s):

Organization(s):

City/Town:

State:

Email Address (Required): *

Phone Number:

Question Title

How many years have you been engaged in AHD-type activities?

Question Title

Does your organization participate in any AHD partnerships?

Yes

Unsure