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ICA Mentorship Scheme - Expression of interest (Mentees)

Personal details

Further details

Please name your preferred mentor(s) (if known)

Please indicate which of the following areas you would like your mentor to support you with.

Knowledge and intellectual abilities
Research governance and organisation
Engagement, influence and impact
Clinical academic leadership skills
Personal effectiveness
Are you willing to take part in evaluation of the mentorship programme?*
Are you willing to allow your biography and image to be used on the programme website and other publicity materials?*

Please note that the team will need to share some of your personal details with University of Birmingham for the purpose of registering you onto the Canvas online virtual learning environment, which will provide you with information on training and events as well as links to useful resources. If you would like to discuss this further or have any questions please email:

ICAMentorshipScheme@uhb.nhs.uk

We will only use the details of this form to handle your query, including responding to you using the contact details supplied where required.

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