Mentee Application Form - Pharmacy Alumni Mentorship Program

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PHARMACY ALUMNI ASSOCIATION

mentee program application form


  Student Contact Information

   Name:
   Email address:
   Campus Mailing Address:
   Campus Phone Number:
 
   Permanent Address:
   Permanent Phone
   Number:
   Cell Phone Number:

   Do you have access to a car for transportation?

    Yes
    No

   Have you had prior pharmacy experience? Please check all that apply.

    Clerk
    Pharmacy technician
    Family business
    Job shadowing experience
    No prior experience
    Other (please describe)


   Site Preferences

      Below are listed various types of practice settings. Click here for a description
      of each type of site. Please select your first, second, and third choices.

   1st Choice:

   2nd Choice:
   3rd Choice:

   If you chose other,
   please specify:

 

Site Location Preferences

   Please tell us which regions you would prefer to be matched in. Within
   the region, please tell us which city you would most like to have a mentor.
   Then, list three other cities within that region as alternatives in case we are
   unable to accommodate your first request.

   Example:
   Region: Madison
   Preferred City: Madison
   Alternatives: Sun Prairie, Verona, Black Earth

 
   Region
   Preferred City:
   Alternative City 1:
   Alternative City 2:
   Alternative City 3:
 

Time of Year Preferences

   Please rank the time of year during which you would like to meet with a
   mentor. Please select your first, second, and third choices.

 
   1st Choice:
   2nd Choice:
   3rd Choice:
   If you chose other,
   please specify:

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