Mentoring Application Form

Mentoring Application Form

PRIMARY CARE TASKFORCE

Mentoring Application Form

NESC Mentoring Pilot Project

This form should be submitted with a ‘Reason for Mentoring’ form. An application cannot be processed without it.

IMPORTANT: Please ring one of the following two options to identify which application route you are following:

  1. Self-Referral

Or,

  1. Appraisal

(In this case you will have discussed making your application at your recent annual appraisal with your appraiser who will, with your permission, have sent NESC a ‘Mentoring Notification’.)

Now please provide your preferred contact details:

Name:

Address:

Telephone number:

E-mail:

Your application should be made to NESC as soon as possible.

You will be notified by NESC whether yourapplication has been successful as soon as possible, and not later than 20th November.

I apply for a place on the NESC Mentoring pilot project and sign in acceptance of the following terms and conditions:

  • I have read and understood the ‘NESC Mentoring Scheme Leaflet’.
  • I expect to be able to make the necessary time commitment for four sessions of mentoring that will take place between December 2009 and the end of March 2010.
  • I understand that a place on the mentoring pilot project is not guaranteed.
  • I understand that whilst I may have expressed a preference for the type of mentoring provision I receive (one to one or group) on the ‘Reason for Mentoring’ form, NESC cannot guarantee fulfilling this request due to the limited numbers involved in this pilot and its evaluation framework. Should this present a problem to me I understand I am free to advise NESC and give up my place.
  • I understand that a mentor will be allocated by NESC and, again, due to the limited numbers involved in this pilot and its evaluation framework there may be limited scope to change mentor if I feel that I could not work with the allocated mentor. However,if others have requested a change I understand NESC will do its best to accommodate my request. If there is no solution I understand I am free to advise NESC and give up my place.
  • I understand that this is a pilot project and as such I will fully comply with the requirements of the evaluation of this project.
  • I understand that should I have any concerns about this scheme I can take them up with Dr Richard Mann (NESC Mentoring Pilot Project Lead) and, if necessary, with Dr Susi Caesar (NESC Appraisal Lead). If the issue is of a significant nature and unresolved the NESC complaints procedure will apply.
  • I enclose with this application form a fully completed‘Reason for Mentoring’ form.

Signed:

Dated:

Please return this form with your ‘Reason for Mentoring’ form by e mailto:

1FINAL 150909

Top View