EMEAC Mentorship - Application MENTOR

**[*] Required information**

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* 1. E-mail address [*]

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* 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

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* 3. Date [*]

Date

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* 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

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* 5. Please declare the main professional area for Mentoring/ Academic advice on

Research

Presentations and lectures

Publications

Applications (grants, funds, other)

Creativity and innovation

Dealing with ethical and moral issues, privacy

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* 6. Clinical work-field advice on

Clinical education

Career-building in clinics

Career-building in private practice

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* 7. Other aspects on

Managing work/family balance

Networking and communication

Other

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* 8. 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

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* 9. What are your scientific areas of interest in clinical neurophysiology

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* 10. Please define your level of experience

Expert in field

Substantial experience for several years after specialisation/PhD

Already some experience, able to support beginners

EMEAC Mentorship - Application MENTOR

[*] Required information

Question Title

* 1. E-mail address [*]

Question Title

Question Title

* 3. Date [*]

Question Title

* 4. Personal and professional information

Question Title

* 5. Please declare the main professional area for Mentoring/ Academic advice on

Question Title

* 6. Clinical work-field advice on

Question Title

* 7. Other aspects on

Question Title

* 8. How much time can you spend on the programme

Question Title

* 9. What are your scientific areas of interest in clinical neurophysiology

Question Title

* 10. Please define your level of experience

Question Title

* 11. What, if any, is your previous experience as a mentor

**[*] Required information**