ACEM Mentor Connect

Last revised: September 2025

Version: 1.1

Form No: F772

Name*

First NameLast Name

ACEM ID*

Email*

example@example.com

Gender*

Region*

Please select the relevant field below:*

Please select what type of ACEM member you are:*

Please select what type of ACEM trainee you are:*

Briefly describe why you wish to become an ACEM mentor:*

Briefly describe your mentoring experience, if any:*

What skills and experience would you bring to a mentoring role?*

Describe your interests, both professional and personal:*

Is there any other information you would like prospective mentees to know as part of the matching process? (eg. you trained overseas, your background etc.)*

Please select all issues or topics you are familiar with and willing to discuss. This will allow us to match you with a mentee that best suits your experiences: *

Please specify your other requirements*

Do you have any preferences, restrictions or limitations that would affect your full participation in ACEM Mentor Connect?*

What communication methods would you prefer to use with your mentee?*

How many mentees do you wish to be paired with?*

Please list the number of mentees you wish to be paired with*

What constraints, if any, do you have in terms of your mentoring commitment?*

Are you looking to mentor a trainee or member? *

Which type of member?*

What type of trainee?*

Acknowledging that mentors will not be matched with a mentee from their immediate hospital network, do you have a preference as to where your mentee is located? *

Please specify the location*

Do you have a preference for the gender of your mentee? *

Please select from the list below*

I acknowledge that:

the ACEM Mentoring Program has been developed to assist members and trainees to connect with another College member or trainee for the purposes of mentoring, pursuant to the ACEM Mentoring Policy and Procedure; and
I have read and understood the ACEM Mentoring Policy and Procedure, and understand the College’s expectations of an ACEM mentor; and
I will be fully responsible for my conduct as a Mentor; and except where otherwise required by regulatory bodies or professional duties, I will maintain the privacy and confidentiality of any mentee(s) with whom I may be paired and comply with the ACEM Privacy Policy; and
some information provided on this application form (*) will be disclosed to mentees during the matching process; and
the College accepts no responsibility for matters arising from the success or failure of my participation in or implementation and conduct of the ACEM Mentoring Program. Please sign below to indicate your acceptance of these terms

I acknowledge:*