OSLHA Mentorship Program - Ohio Speech-Language-Hearing-Association

Candidate Information

I AM A:*

Student
Professional - SLP
Professional - Aud
Professional - Dual-Licensed

I Am Interested in*

Being Mentored
Serving as a Mentor to Others

CANDIDATE NAME:*

CANDIDATE ADDRESS:*

CANDIDATE CITY / STATE / ZIP CODE:*

CANDIDATE EMAIL:*

DAYTIME PHONE:*

ALTERNATE PHONE:

YEARS IN THE PROFESSION:*

AREA OF SPECIALIZATION:

EMPLOYER:*

UNIVERSITY I ATTEND:*

Area of Interest

Select all that apply

Indicate the Type of Mentorship You are Seeking:*

Indicate the Area Where You are Seeking Mentorship:*

Indicate the Type of Mentorship You are Interested in Providing:*

Indicate the Area Where You are Willing to Provide Mentorship:*

Availability

Select all that apply

Days of the Week I am Available to Participate*

Times of Day I Am Available to Participate:*

Mornings
Afternoons
Evenings
Weekends

Candidate Perspective:

Provide insight on the following so we can match you up in the most valuable mentorship relationship

Write a Brief Statement On Why You Would Like to Participate in our Mentorship Program:*

Candidate Acknowledgements

Membership Requirement*

I ackowledge and agree

I Acknowledge that I Will be Required to Obtain and Retain an OSLHA Membership for Eligibility as a Participant in the OSLHA Mentorship Program.

Time Commitment*

I ackowledge and agree

I Understand That the Mentorship Program Involves Spending Time and Communicating with the Determined Mentee and that These Times will be Set Between the Mentor and Mentee.

Participation Period*

I ackowledge and agree

I Understand That the Mentorship Program Will Require My Active Participation for a Minimum of 12 Months.