EMEAC Mentorship - Application MENTEE

**[*] Required information**

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* 1. E-mail address [*]

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* 2. I grant permission to the EMEAC to *

1. Collect my personal/the collective entity I represent data for the EMEAC records.
2. Use and make use of my contact information (name, email, address, phone number) for communication purposes (solely for purposes related to the mentorship program)

I am informed that I have the right to withdraw the present consent at any time

Agree

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* 3. Date [*]

Date

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* 4. Personal and professional information

First Name

Last Name

Title

Hospital/Institution name and address

Country of residency / your Institution

Current position

Gender

Languages spoken

Year of obtaining degree of specialty in neurology/clinical neurophysiology or acedemic position

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* 5. What are your scientific areas of interest in clinical neurophysiology

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* 6. Please declare the main professional area where you seek mentoring/Academic advice on

Research

Presentations and lectures

Publications

Applications (grants, funds, other)

Creativity and innovation

Dealing with ethical and moral issues, privacy

Other

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* 7. Clinical work-field advice on

Clinical education

Career-building in clinics

Career-building in private practice

Other

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* 8. Other aspects on

Managing work/family balance

Networking and communication

Other

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* 9. What are the most motivational factors for joining this mentoring program

Improving scientific output

CV improvement

Improving clinical output

Networking

Better work-life balance

Other

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* 10. How much time can you spend on the programme

1-2 hours per month

1-2 hours every 2nd month

1-2 hours every 3rd month

1-2 hours every 4th month