Clinical Mentor Application -Tender Touch

Employee Name*

First

Middle

Last

Cell Phone Number*

Email address*

Facility Name*

Discipline*

Current Role*

Do you have 5 years of experience working as a clinician?*

Yes

What is the original date of your licensure?*

I am sorry but you are not eligible to apply for this role at this time.

Do you have 3 years of experience working at Tender Touch?*

Yes

What is your Tender Touch date of hire?*

I am sorry but you are not eligible to apply for this role at this time.

What is the name of your Regional Manager or Rehab Director reference?*

What is the email address of your Regional Manager or Rehab Director reference?*

What is the name of your Clinical Co-Worker reference?*

What is the email address of your Clinical Co-Worker reference?*

Which type of Mentor are you applying to be?*

Staff Mentor

DOR Mentor

Why do you want to be a clinical mentor and what qualities do you possess that will make you a good mentor?*

Comments

I certify that all information given by me in this application is true, accurate and complete to the best of my knowledge. I understand that any false information, misrepresentation or omission of any information from this application will make me ineligible to participate in the Clinical Mentor Program.*

Yes

I hereby authorize the references listed in my application to give all information concerning my employment, skills, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered in this application and release all such parties from all liability that may result from furnishing such information to Tender Touch.*

Yes

It is the responsibility of the applicant to ensure their 2 references send the reference form to HR@tendertouch.com

Tender Touch is an Equal Opportunity Employer. Unlawful discrimination because of age, race, sex, color, religion, national origin, physical or mental handicap, or status as a disabled veteran of the Vietnam era is prohibited under local, state and federal law.

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