PNIMR

 

PHILIP NELSON INSTITUTE   OF MEDICAL RESEARCH.

APPLICATION  AND AGREEMENT FORM  FOR MENTORSHIP.

 

  1. NAME OF MENTOR:…………………………………………

CONTACT DETAILS: ……………………………………………………

ADDRESS OF MENTOR:……………………………..........................

TELEPHONE:…………………………………………………………….

EMAIL:……………………………………………………………………

WEBSITE:…………………………………………………………………

GENDER:…………………………………………………………………

RESEARCH INTERESTS:…………………………………………………

SKILLS:…………………………………………………………………..

ACADEMIC ACHIEVEMENTS:…………………………………………

2. NAME OF MENTEE:…………………………………………………

ADDRESS OF MENTEE:…………………………………………………

TELEPHONE:…………………………………………………………….

EMAIL:……………………………………………………………………

WEBSITE:………………………………………………………………..

GENDER:……………………………………………………………….

RESEARCH INTERESTS:………………………………………………..

SKILLS:………………………………………………………………….

MENTEE GOALS:………………………………………………………

ACADEMIC ACHIEVEMENTS:………………………………………….

SUPPORT NEEDED FROM MENTOR:………………………………...

TARGET DATE:…………………………………………………………..

AMOUNT PAID:………………………………………………………..

  1. DECLARATION:  We are voluntarily entering into a mentoring relationship that we expect to benefit all participants as well as our organization.

 We expect this to be a rewarding experience , with most of our time spent on substantive development activities.

To ensure a positive relationship, we agree to the following :

 

We define confidentiality as follows:…………………………

Duration of relationship:………………………………………….

Frequency and length of meetings:………………………………

We will review our progress after…………………….months.

We have defined the context of this relationship as:…………………………………………………………………..(career development, skills development, orientation to organization or position etc.).

We have agreed to focus on the goals and actions outlined below:…………………………………………………………….

……………………………………………………………………………………………………………………………………………..

We agree to a no- fault conclusion of this relationship , if for any reason , it seems appropriate.

SIGNED AND DATED BY PARTNERS IN THIS AGREEMENT.

NAME OF MENTEE:……………………………………………

SIGNATURE:…………………………………………………….

DATE:………………………………………………………………

NAME OF MENTOR:……………………………………………

SIGNATURE:…………………………………………………….

DATE:………………………………………………………………

PLEASE RETURN THIS APPLICATION FORM WITH US$ 40 = ONLY  AFTER COMPLETION TO RECEIVE A MENTORING HANDBOOK .

PLEASE RETURN THIS FORM TO: philipnelsoninstitute@yahoo.com