CATA Mentorship Program Sign-Up (Spring 2020)

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The purpose of this program is to:

Purpose
1. To encourage “Established Professionals,” “Young Professionals” and Athletic Training Students to network with each other to build a stronger Athletic Training Community in the State of Connecticut.
2. To encourage “Young Professionals” and Athletic Training Students to gain a larger interest in the Athletic Training Profession and to encourage more involvement on the State/District/National Level.
3. To create networking opportunities for Mentorship Program Members at annual CATA Symposiums.

Mentor/Mentee applications will be accepted until March 30, 2020. Pairings will be announced no later than April 10, 2020 via an email to the participants. Please email cataypc@gmail.com with any questions.

First Name: *

Last Name: *

Age: *

Email address: *

Mobile phone number: *

Number of years practicing as an athletic trainer *

0 years (student)

1-4 years (Mentee)

5-12 years (Junior Mentor)

12+ years (Senior Mentor)

Which University do you live or work closest to? *

Central Connecticut State University

Quinnipiac University

Sacred Heart University

Southern Connecticut State University

UConn

Job setting *

Secondary school (employed by the district/school)

Secondary school (employed by a clinic/hospital)

Clinic - Inpatient hospital

Clinic - outpatient

College/University - Athletics

College/University - Faculty/Administration

College/University - Split Appointment

Professional Sports

Hospital - Orthopedics

Industrial/Occupational

Amateur/Youth Sports

Independent Contract

Health/Fitness

Corporate

Military/Law enforcement

Other:

Place of employment *

Undergraduate school and Graduation Year *

Graduate School and Graduation Year (If applicable) *

NATA Number *

CT License Number *

BOC Certification Number *

NPI Number

Please describe your interest in joining the CATA YPC Mentorship Program *

Please provide one goal you are hoping to achieve from your participation in the CATA YPC Mentorship Program. *

Will you be available and able to communicate monthly with your mentor group? *

Yes

Have you ever received an disciplinary or corrective actions? *

Yes

If yes, please explain:

Additional comments

Please provide your initials as your eSignature *

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