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EMEAC Mentorship - Application MENTEE
[*] Required information
1.
E-mail address [*]
2.
I grant permission to the EMEAC to *
1. Collect my personal/the collective entity I represent data for the EMEAC records.
2. Use and make use of my contact information (name, email, address, phone number) for communication purposes (solely for purposes related to the mentorship program)
I am informed that I have the right to withdraw the present consent at any time
Agree
3.
Date [*]
Date
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
4.
Personal and professional information
First Name
Last Name
Title
Hospital/Institution name and address
Country of residency / your Institution
Current position
Gender
Languages spoken
Year of obtaining degree of specialty in neurology/clinical neurophysiology or acedemic position
5.
What are your scientific areas of interest in clinical neurophysiology
6.
Please declare the main professional area where you seek mentoring/Academic advice on
Research
Presentations and lectures
Publications
Applications (grants, funds, other)
Creativity and innovation
Dealing with ethical and moral issues, privacy
Other
7.
Clinical work-field advice on
Clinical education
Career-building in clinics
Career-building in private practice
Other
8.
Other aspects on
Managing work/family balance
Networking and communication
Other
9.
What are the most motivational factors for joining this mentoring program
Improving scientific output
CV improvement
Improving clinical output
Networking
Better work-life balance
Other
10.
How much time can you spend on the programme
1-2 hours per month
1-2 hours every 2nd month
1-2 hours every 3rd month
1-2 hours every 4th month
