Mentors Registration Form - second pilot 1 November 2021 to 31 March 2022

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* 1. Your name

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* 2. Email address

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* 3. Mobile phone number

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* 4. City or Town

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* 5. Current role

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* 6. Specialism e.g. Mental Health, Children etc

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* 7. Sector e.g. NHS, etc

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* 8. What motivated you to become a mentor for the ECT Mentoring Programme pilot?

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* 9. What type of mentee(s) would you like to work with?

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* 10. Tell us a little bit about yourself and your career to help us match you to a suitable mentee

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* 11. How many mentees are you willing to take on (we recommend a maximum of three mentees)

one mentee

two mentees

three mentees

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* 12. Your age

Under 20

21-30

31-40

41-50

51-55

56-60

61-65

66-70

71-75

Above 75

Prefer not to say

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* 13. Do you have a disability or long term health condition

Yes

Prefer not to say

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* 14. Your ethnicity

white British, English, Northern Irish, Scottish or Welsh

Irish

Gypsy or traveller

Any other white background

White and black Caribbean

White and Black African

White and Asian

Any other mixed or multiple ethnic background

Asian or Asian British

Indian

Pakistani

Bangladeshi

Chinese

Any other Asian background

Black Caribbean

Black African

Any other black, African or Caribbean background

Arab

Prefer not to say

Mentors Registration Form - second pilot 1 November 2021 to 31 March 2022

Question Title

* 1. Your name

Question Title

* 2. Email address

Question Title

* 3. Mobile phone number

Question Title

* 4. City or Town

Question Title

* 5. Current role

Question Title

* 6. Specialism e.g. Mental Health, Children etc

Question Title

* 7. Sector e.g. NHS, etc

Question Title

* 8. What motivated you to become a mentor for the ECT Mentoring Programme pilot?

Question Title

* 9. What type of mentee(s) would you like to work with?

Question Title

* 10. Tell us a little bit about yourself and your career to help us match you to a suitable mentee

Question Title

* 11. How many mentees are you willing to take on (we recommend a maximum of three mentees)

Question Title

* 12. Your age

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* 13. Do you have a disability or long term health condition

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* 14. Your ethnicity

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* 15. Do you need any adjustments to be able to fully participate in the ECT Mentoring Programme pilot e.g. large print, sign language interpretation?