East of England Leadership Academy

MentorNet

Register as a mentee

To register as a mentee, please complete this form, filling in the requested information or ticking the boxes. The more information you provide, the easier it will be for us to match you to the right mentor.

To move between sections, click 'Next' or the required tab. When you have completed all sections, please click 'Submit my application now'.

nb. please do not use your browser's 'Back' and 'Forward' buttons, otherwise you may lose information that you have entered.

Mentoring standards

Consent to storage and use of your personal data *

About you

Please tell us some details about yourself.

* denotes a required field

Title  
First name *
Last name *
Job title *
County / region *
Organisation *
Address *


Town *
Postcode *
Telephone number *
Alternative telephone number
E-mail address *
Do you have a clinical background? If yes, please provide details*
Are you a practising clinician? *
What is your payband? *
(Mentors on this register are available to staff at Band 4 or equivalent and above)
Have you agreed that you will have time for mentoring as part of your development with your manager or agreed it as part of your PDP with your Education Supervisor? * Yes
Please select one of the options if you have undertaken, or are currently on, one of the following programmes or are a member of a network: *
























  –  please describe:
Where did you hear about MentorNet? *




Objectives

Please tell us what you are hoping to achieve from your mentoring.

* denotes a required field

Any specific mentoring requirements or reasons for seeking mentoring at this time: This information will be made available to potential mentors to help them decide whether they would be well placed to mentor you.
My current position: (please tick all that apply) *











I require a mentor with a professional background in: (please tick all that apply) *


















I require a mentor to work with me to assist with: (please tick all that apply) *



Logistics

Please tell us how you would prefer your mentoring to work in practice.

* denotes a required field

I am looking to enter into a mentoring relationship that is: (please tick all that apply) *

I would prefer my mentoring to be based within the following geographical area: *




I would prefer my mentoring to be: *

Equality monitoring

The following questions are for equality monitoring purposes only, and the information provided will not be made available to other users:

Are you: *

Do you now, or have you ever considered yourself to be transgender *

What is your age group? *








What is your ethnic group? *















Please indicate your religion or belief *











Please indicate which term would best describe your sexuality *




Are you currently providing support to a partner, child, relative, friend or neighbour who could not manage without your help and / or support?: *

Do you have a disability? *
A disabled person is defined in the Disability Discrimination Act as someone with a physical or mental impairment that has a substantial and long term impact on their ability to carry out day-to-day activities

If you answered yes, and would like to, please indicate the nature of your disability (tick as many as are applicable)





 

East of England Leadership Academy Coaching and Mentoring Register is based on the CRBhub management system from CRB Associates