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

    Site Information

       Please check all of the following that apply to your site.
        Hospital
        Independent Community Pharmacy
        Chain Community Pharmacy
        Long Term Care
        Managed Care
        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.


Time of Year Preferences

    Please rank the time of year during which you would like to meet with a student.
    Please select your first, second, and third choices.
    Click here to see approximate dates of these descriptions.
 
   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):


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.)
   

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