Application for Mentor

Name:

Age:

Medical registration number:

Qualification:

Designation:

Hospital :

City :

Country :

Specific area of interest/ expertise in Nephrology:

Details on experience in teaching/ mentoring:

Contact details:

Email

Phone no:

Postal address:

Choose from the list below the domains of interest for the mentorship:
—Please choose an option—Clinical researchBasic scienceClinical skillsNephro-pathologyInterventional nephrologyPediatric NephrologyClinical EthicsCarrier developmentLeadershipCollaborative skillsCommunication skillsTransplantationImmunologyCRRTCAPD

Proposed type of mentoring :

Proposed duration of mentorship :

Frequency of contact with mentee :

Preferred mode of contact with the Mentee:

Would you be willing to provide feedback on the progress of the mentorship?

Additional information