Form 07
Report of the (Required) Mentor Relationship Applicant Name:
______________________________________________________________________________________
Email address:
______________________________________________________________________________________
District:
[__] AP [__] CM [__] HI [__] MV [__] NR [__] SS [__] SM [__] TV [__] TR
General Instructions: • The Candidate is responsible for uploading completed Form and any attachments to the DCOM registrar. • Mentor and mentee should complete the following together Please answer for the current credentialing (Annual Conference) year. The candidate may also request a prior year mentor to provide additional information, especially if meeting with the DCOM in the Fall. For the Candidate to Complete: For the current credentialing (Annual Conference) year, I am participating in (select one): [__] Individual mentoring (approved by the Conference Registrar) [__] Participating in a Clergy Covenant or other such similar group. [__] Residency program [__] Year 1 [__] Year 2 [__]Year 3 [__]Year 4+ [__] Other (please describe) ________________________________________________________________________ If participating in group mentoring, indicate the type and format of the group (select one): [__] Skype or tech-based [__] In person For the Mentor to Complete: Number of meetings/contacts (to date) for group or individual mentoring. Has the mentee participated in all scheduled mentoring? Has there been mentoring outside of scheduled opportunities? If so, how often? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________
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Updated: 2020-11
For the Mentee and Mentor to Complete: 1. What topics have you addressed in your conversations this year? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 2. What other non-evaluative, descriptive information do you wish to include? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ __________________________________________ Printed Name of Mentor __________________________________________ __________________________ Signature of Mentor Date __________________________________________ __________________________ Signature of Candidate Date
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Updated: 2020-11