NOBIDAN Mentor Application
Name
First Name
Middle Name
Last Name
Credentials
Academy Member Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you a current NOBIDAN member? If so, what membership category?
Student
Active
Retired
International
Not a current NOBIDAN member
Email
example@example.com
Cell Phone Number
-
Area Code
Phone Number
What is your current or last area of practice?
How long have you practiced in your field?
What is your racial/ethnic background? Check all that apply.
Black / African American
American Indian / Alaska Native
Asian
Hispanic / Latino
Middle Eastern or North African
Native Hawaiian / Other Pacific Islander
White or Caucasian
I prefer not to disclose this information
Other
What is your area of expertise or focus? Check all that apply.
Business/Industry
Clinical Nutrition, General
Communication/Publication
Community Nutrition
Consultation and Private Practice
Diabetes Care
Education
Food and Nutrition Management/Administration
Food Service
Gerontology
Integrative/Functional Nutrition
Long-Term Care
Nutrition Support
Oncology
Pediatric
Policy/Advocacy
Renal Nutrition
Research
School Nutrition
Weight Management
Wellness/Prevention
Other
What type of guidance can you provide? Check all that apply.
Dietetic Internship/RD Exam Support
Job Opportunities/Networking
Resume Guidance/Interviewing Skills
Management/Leadership Skills
Academic Support
General Career Guidance
Social Media/Technology
Career/Student Challenges with being a minority
Other
If you had a choice, who are you most comfortable mentoring? Check all that apply.
Student - Undergraduate
Student - Graduate
Dietetic Intern
New RD (less than 5 years in the field)
What is your preferred method of communication? Check all that apply. (Note: While the Mentorship Program Committee will do our best to match mentors and mentees that are in the same geographic area, it is likely that the mentor and mentee will be in different locations and maintain their relationship by other means of communication.)
Email
Text Message
Phone Calls
Virtual Meeting such as Skype, Google Hangout, etc.
If you prefer a virtual meeting, what platform(s) are you familiar with? Check all that apply.
Zoom
Skype
Google Hangout
Google Meet
WEBEX
GoToMeeting
FaceTime
Other
How comfortable are you with technology?
Very Comfortable
Comfortable
Neutral
Uncomfortable
Very Uncomfortable
What do you hope to gain from participating in this mentorship program?
0/200
Is there anything else you would like to share to assist with the matching process?
0/200
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