Name (First, Last)

Degrees held:

Position:

Hospital address:

Email address:

Phone Number:

Years from completion of formal training:

Specialty (please tick one)

Specific area(s) of Interest:

Level of research experience

Preferred language (please tick all that you are happy to use):

Please mention if you prefer a mentor from a high income or low/middle income country (optional):

How often would you like to meet/interact with your mentor:

Suggest a name(s) of a person you would like to be mentored by (optional)

What is your background in paediatric oncology? (75 words)

What are your current interests within paediatric oncology? (75 words)

What would you like to get out of this mentorship programme? (75 words)