If you have any questions about the application, please mail the Mentoring Programme team at mentoring@iiop.ie Applications close on Sunday 27 April Complete the following form YOUR PROFILE Name: First Name Last Name Gender: - Select -MaleFemaleNon-binaryPrefer not to say Phone number: Email: Email: Confirm email YOUR PHARMACY PRACTICE PSI Number: Primary Practice area: Primary Practice area: - Select -CommunityHospitalIndustryEducationResearchOther… Enter other… Please list your qualifications: Number of years qualified as a pharmacist: Current Position: Time in current role: Areas of expertise/ special areas of interest: THE MENTORING PROGRAMME Describe yourself in 3 words: Describe your ideal mentor in 3 words: Why do you want to be a mentee for this mentoring programme? People come to mentoring for a wide range of reasons. To help us find a good match of a mentor for you, please let us know if you have a particular goal you want to work towards with a mentor? EXPERIENCE- MENTORING Have you been a mentor or mentee previously informally or in a programme? - Select -Yes, Mentor onlyYes, Mentee onlyYes, both Mentor and MenteeNo, neither Mentor or Mentee If yes, please describe your experience (concisely) incl. duration of experience: DECLARATION OF SUITABILITY - TO ENSURE THE QUALITY OF THE PROGRAMME, WE ASK YOU TO DECLARE YOU UNDERSTAND THE EXPECTATIONS OF BEEN A MENTEE. PLEASE REVIEW THE INFORMATION BELOW AND SIGN THE DECLARATION, AS APPROPRIATE. MENTEE SELF-ASSESSMENT EXPECTATIONS OF MENTEES (Click box to agree to all) Retain ownership of my development and my actions Identify my learning needs when it comes to reflective practice Plan with my mentor how to meet those needs Be open and honest, and committed to my development Have put thought into my development before any mentoring sessions in order to fully benefit Respect and value my mentors time and use it wisely Evaluate the relationship periodically and follow through on commitments I have completed the self-assessment above I confirm that I am available on the evening of the 19th of May for an onboarding session (via Zoom) I confirm that I am in good professional standing Name: Date: I consent to being contacted by text or whatsapp in relation to this programme Mobile Number Submit
