MENTOR-AFE Mentor Candidate Profile form

Personal information

* Surname/Family name

* First name

* Prefix
Check any that apply
* Language(s) that you could use in the mentorship

* Current title (work) and organisation

* Full mailing address (including state/province and country)

* Phone number (include country code)

* Email address

* Skype or other video-chat username(s) and platforms

Mentorship

* In 500 words or less, please outline any previous experience you have as a mentor.  Include experience in similar roles, such as coaching, supervising, or teaching. 

* In 300 words or less, please outline why you think you would make a good mentor. 

Experience and skills

* Please briefly outline any past or present involvement you’ve had with the development of age-friendly cities and communities. Note: Experience in age-friendly environments is desirable but not essential.    

Please list your three most relevant qualifications and the year in which the qualifications were completed.
  Qualification (degree, programme) Institution Year completed
1
2
3
* Check all of the skills listed below that you have experience in and could offer mentorship with.
Check any that apply
* Please provide further information about your experience with each of the skills selected.

* Considering the skill sets and activities listed above, please list the top three skills you would be most prepared to help develop within a mentee.

Availability and preferences

* How many hours per month do you anticipate you could spend on communications (emails, phone calls ) and non-communication related tasks (i.e. reviewing your documentation, compiling supporting materials) with a mentee?
* Are there any limitations in relation to what you could offer as a mentor that we should be aware of, or any preferences for the mentee (eg. lives in the same country)? 

* What are your expectations of a mentee, for example, in terms of time commitment, qualities and actions?

Agreement

* By submitting this form, I confirm that the information provided is accurate to the best of my knowledge.  I understand that there is no financial provision for mentoring, and that the costs of participating will be met by me or an organization that has agreed to support me in this way.  I also understand that the pilot of the MENTOR-AFC will be limited to 20 pairs, and that my participation will depend in part on whether there is an appropriate mentee for me.  Should I not be matched with someone, I may be contacted in future to see if I am still available and interested in being a mentor. 
 
Signed (enter your first and last name)
Date