NCHIMA Mentor Application

First Name

Last Name

AHIMA ID# This question requires a valid number format.

NCHIMA Region

College (most recent)

Degree

Credentials

Employer This question requires a valid email address.

Daytime Phone

Evening Phone

Cell/Pager

Email Address This question requires a valid email address.

I am easiest to reach (days/times)

I check my email:

How do you prefer to be contacted?

How would you prefer to meet with your assigned mentee?

Address

City

State

Zipcode

HIM Field where currently employed (if applicable):

HIM Field where you can provide expertise: (please select all that apply)

A local match might not be able to be made for you if you prefer in-person meetings so you should have internet access, access to a phone, a headset, speakers for your computer, and a microphone so that you can participate in conference calls or webinars with the mentor. If meeting your mentor in person, you will need to arrange for transportation to meet your mentor.

Participating in the program requires a time commitment from both mentor and the mentee. What kind of time commitments do you feel you can make?