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MENTOR PROGRAM APPLICATION
Date_____________
Name____________________________________________________________________
Last First Middle
Residence Address: _________________________________________________________
Telephone: Home________________ Office_________________ Cell. _____________
E-mail __________________________
Education:
Undergraduate degree _______________ Year________ University ___________________
Graduate degree _______________ Year________ University ___________________
Concentration:____________________________
First Year Practicum: _________________________________________________________
Second Year Practicum: _______________________________________________________
Employment:
Full time: Yes_____ No ____ Part Time: Yes_____ No ____
Position:_______________________________
Employer Name and Address: __________________________________________________
Requirements:
1. Membership in the Clinical Social work Society of Hawaii (CSWSH)
2. Submitting a completed CSWSH Mentorship contract
3. Regular participation in a CSWSH Mentorship group
4. Commitment to the CSWSH Mentorship Program for at least 10 month of a calendar year
Please return the contract together with your completed application to CSWSH to:
Nicholai M. Khiterer, Psy.D., LCSW, 300 Wai Nani Way #818, Honolulu, Hawaii 96815
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