Local Health Department Directors of Nursing Mentorship Program

Mentee Application Form

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* 1. Full Name (First, Last):

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* 2. Email:

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* 3. Phone Number:

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* 4. County:

Commitment:

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* 5. Are you committed to meeting with your mentor at least monthly for 6 months?

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* 6. Are you committed to an attitude of learning by maintaining a positive mindset?

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* 7. Are you committed to maintaining professionalism, and communicating with your mentor openly and honestly?

Experience:

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* 8. How many years of experience do you have as Director of Nursing in local public health? 

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* 9. Please list other public health and nursing management experience:

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