Application Form

First and Last Name

Rank

Department

Preferred Email

Preferred Phone

WHAT IS YOUR MAIN REASON FOR REQUESTING A MENTOR?

Academic Development Clinical and Professional Development Support and Fulfilment

Any others (please provide details below)

WHAT SKILLS ARE YOU LOOKING TO ACQUIRE/IMPROVE?

Examples include but are not limited to: Administrative skills, management skills, leadership skills, research skills, interpersonal skills, teaching and training skills, clinical skills, social connections, writing skills, presentation skills, public speaking, building collaborations, work-life balance, academic credentialling and promotion, CV preparation or any other items that could help prepare you to reach their career goals.

MENTOR PREFERENCES

Would you prefer someone from your own discipline?

Please provide the names of 2-3 mentors you would like to work with.

For how long would you like to receive mentorship? (Typically agreement duration is 12-18 months)

Any other preferences or information that would aid in the mentor selection

Disclaimer:

The University of KwaZulu-Natal (UKZN) confirms that all personal information (as defined in the Protection of Personal Information Act 4 of 2013) provided will be treated confidentially and will not be will be processed and handled as per the Act neither will it be sold to a third party or used for commercial or related purposes.

School of Medicine Mentoring Programme

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