East of England Leadership Academy


Register as a mentor

To register as a mentor, please complete this form, filling in the requested information or ticking the boxes. The more information you provide, the easier it will be for prospective mentees to make a request to you.

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

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

Telephone number *
Alternative telephone number
E-mail address *
Do you have a clinical background? If yes, please provide details*
Are you a practising clinician? *


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

* denotes a required field

Level(s) of staff to whom you are able to consider providing mentoring: (please tick all that apply) *

My professional background(s): (please tick all that apply) *

I am able to offer mentoring in: (please tick all that apply) *


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

* denotes a required field

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

I am able to provide mentoring within the following geographical area: *

I am able to provide mentoring which is: *
Please indicate the level of your experience as a mentor and provide any comments on your preferred style / approach *
Mentoring arrangements, eg preferred venue / travel arrangements *
Training / experience *

Please provide a few details about your personal interests / background
Any other useful information
I have attended the Aspire Together Aspirant Director Career Mentor Programme and can support Ready Now / Ready Soon Aspirant Director Talent Programme Participants
Supporting document
e.g. biography – optional (Word, Excel or PDF files accepted)
Number of mentoring relationships I am willing to have at any one time *

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