ACEM Mentor Connect (Mentee)

Last revised: September 2025

Version: 1.1

Form No: F776

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 mentee:*

Briefly describe your mentoring experience, if any:*

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

Please specify your other requirements

What are the immediate/short-term focus points that you would like to discuss with a mentor? (e.g. exam preparation, interview skills, professional interactions, etc.)*

What are your long-term focus points that you would like to discuss with a mentor? (e.g. balancing life and work, career aspirations, planning for retirement, etc.)*

Describe your interests, both professional and personal:*

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

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

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

Are you looking for a trainee or member mentor?*

Which type of member mentor?*

What type of trainee mentor?*

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*

Are there any other attributes you are seeking in a mentor?*

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:*