Black Nurse Network Mentor Application

Name *

First Name

Last Name

Phone

(###)

###

####

Best mode of contact (select all that apply) *

Phone

Text

Email

Best time to contact *

Morning (8am -12pm)

Afternoon (12pm - 5pm)

Evening (5pm - 9pm)

Weekdays

Weekends

Credentials *

LPN

ADN-RN

BSN-RN

MSN

MSN

NP

DNP

Ph.D

ed.D.

Other...

Have you been a nurse for at least two years? *

Yes

No

Are you willing to commit to at least one year of mentoring? (August - May) *

Yes

No

Are you willing to attend Mentor Orientation? *

Yes

No

Are you willing to attend all required events? *

Yes

No

Are you willing to complete the monthly check-in form? *

Yes

No

Choose the number of mentees you would like this year *

One

Two

Please select a t-shirt size below

Small

Medium

Large

X-Large

XX-Large

Other