LRBNAA Mentorship Program
Mentor Application
Place your cursor on the shaded area and begin typing.
Date:
First Name
Middle Initial
Last Name
Credentials
Nursing License #
Mailing Address
Street or P.O. Box
Apt #
City
State
Zip Code
Home Phone
Cell Phone
Email address
Gender (Please check):
Male
Female
Age (Please check):
25 or younger
26-29
30-39
40-49
50-59
60-69
Race/Ethnicity (Please mark all that apply):
Caucasian, Non-Hispanic
Black, Non-Hispanic
Asian
Hispanic
American Indian
Pacific Islander
Alaskan Native
Other:
Highest Level of Education Completed:
Diploma in Nursing
Associate Degree in Nursing
Associate Degree in Other Field
70 and older
Bachelor’s Degree in Nursing
Bachelor’s Degree in other field
Master in Nursing/Specialty Area
Master in other field
Doctorate in Nursing (Specify):
Doctorate in other field
Juris Doctor (JD)
Educational Background:
High School Name:
Location:
Year of Graduation:
Nursing Program:
Location:
Year of Graduation:
Other College/University:
Location:
Year of Graduation:
Degree/Certificate:
Other College/University:
Location:
Year of Graduation:
Degree/Certificate:
Other College/University:
Location:
Year of Graduation:
Degree/Certificate:
Current employer:
Location:
Years employed:
LRBNAA | www.lrbnaa.org
How many years have you been a nurse?
Position/Title:
Chief Nursing Officer
Consultant
Educator
Managed Care/Case Manager
Nurse Manager
Nurse Practitioner
Researcher
Staff Nurse
Public Health Nurse
Clinical Nurse Specialist
Director
Health Policy Analyst
Nurse Anesthetist
Nurse Midwife
Quality Assurance/Improvement
Risk Management
Supervisor
Other:
Area of Practice: (Please mark all that apply including current & previous experience)
Acute Care
Ambulatory Care
Cardiovascular
Corrections
Diabetes
Emergency Department
Genetics/Genomics
Health Policy
Holistic Nursing
Hospice & Palliative Care
Infusion
Long-Term Care
Neonatal
Neurology
Oncology
Orthopedics
Pediatrics
Research
Psychiatric/Mental Health
Women’s Health (OB/GYN)
Other:
Administration/Management
Anesthesia
Case Management
Critical Care (ICU, CCU, SICU)
Educator
Ethics
Gerontological Nursing
HIV/AIDS Care
Home Health
Informatics
Legal Nurse Consultant
Medical/Surgical
Nephrology
Occupational Health
Operating Room
Pain Management
Primary Care
Perioperative
Rehabilitation
Wound Care
Other:
Please mark all of following in which you have expertise and are able to provide a presentation:
PowerPoint
Local Resources
Writing Abstracts
Poster Presentation
Other:
Social Media
Financial Aid
Study Skills
Student Programs
Entrepreneurship
Life Skills
NCLEX preparation
Writing for Publication
Drug Math
Are you a member of any of the following professional nursing organizations?
(Please mark all that apply)
Little Rock Black Nurses Association of Arkansas
National Black Nurses Association (NBNA)
LRBNAA | www.lrbnaa.org
Arkansas Nurses Association (ArNA)
American Nurses Association (ANA)
American Academy of Nurse Practitioners
American Assembly for Men in Nursing
American Academy of Nursing
Emergency Nurses Association
Sigma Theta Tau International
National Association of Hispanic Nurses
Southern Nursing Research Society
National Association of School Nurses
Transcultural Nursing Society
Oncology Nursing Society
Wound, Ostomy & Continence Society
Other:
Other:
Are you a member of a fraternity or sorority?
Yes
No
If yes, what is the name of the fraternity or sorority?
If you are a member of a church or other religious group please provide the name and location:
Describe your personality or how others would describe you:
List your personal interests, activities, hobbies, etc.:
How many students are you willing to mentor?
_____________________________________________________________________________________
I agree to be a mentor in the LRBNAA Mentoring Program and I am committed to fulfilling the duties and
responsibilities required as a mentor.
You will be asked to provide a written signature upon assignment
Name:
Date:
Please send completed applications to KJBryant@uams.edu
LRBNAA | www.lrbnaa.org