Mentor Program Application - Pharmacy Alumni Association

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PHARMACY ALUMNI ASSOCIATION

mentor program application


Mentor Contact Info
   Name:
   Email address:
   Work Mailing Address:
   Work Phone Number:
 
Optional Contact Info
   Home Mailing Address:
   Home Phone Number:
   Cell Phone Number:

Do you have Internet access at your workplace?          Yes     No
Supervisor Name:
Supervisor Email:

    Site Information

       Please check all of the following that apply to your practice:
        Hospital
        Independent Community Pharmacy
        Chain Community Pharmacy
        Long Term Care
        Managed Care
        Home Health
        Administrative
        Academia
        Other (please describe)

    Please provide a brief description of your pharmacy and/or any unique offerings
    at your site:

   Example: XYZ Pharmacy is an independent pharmacy serving a community of 5000 patients. We package medications in unit dose form for our patients. We also fill med boxes for residents at a local assisted living center. Please include the name of the pharmacy/institution.


    Position Information

     Please check all that apply to your position description category:
        Practitioner
        Administrator
        Faculty
        Researcher
        Industry Representative
        Liaison
        Other (please describe)

 

Time of Year Preferences

   New in 2009: Matches will be made one time for the year in order to promote
   frequent meetings and avoid scheduling conflicts.
 
   1st Choice:
   2nd Choice:
   3rd Choice:
   If you chose other, please specify:

 
   Please list any specific time-of-year
   (restrictions for example,
   commitments at professional
   meetings, personal vacations, or other
   obligations):


    Availability

     Would you be willing to meet with more than one student at a time?
        Yes
        No

   Please list the maximum number of students you would be willing to mentor within
   a given period of time. (For example, no more than 2 students per time frame, or,
   no more than 4 students per year.)
   

Have you completed a residency?   Yes     No

If Yes, please specify:
       Type of residency:
       Location:


Please forward any questions to:
   Mentor Program Coordinator
   UW School of Pharmacy, Mailbox # 14
   777 Highland Ave
   Madison, WI 53705
   Email