Name:
Address:
Phone:
Cell:
Personal Email:
Work Email:
Employer:
1. How long have you been a Central Florida ASTD Member?
Less than three months
4 months to 1 year
1-3 years
3-5 years
5-7 years
7-9 years
10-15 years
15-20 years
more than 20 years
2. How many years have you worked in the learning/performance improvement industry?
less than 1 year
1-3 years
3-5 years
5-7 years
7-9 years
10-15 years
15-20 years
20-30 years
more than 30 years
3. Select 1-2 skills/competencies that you utilize most in your current career, or which best describes your current position:
Designing Learning / Content Development
Managing the Learning Function
Improving Human Performance
Coaching
Delivering / Facilitation Training
Managing Organizational Knowledge
Measuring & Evaluation
Career Planning & Talent Management
Facilitating Organizational Change
e-Learning
Other
4. Of those above selected; list and rank what percentage of your work time is spent on each (Example: Delivering Training – 10%, Designing Learning – 90% OR Designing Learning 100%)
5. Select any skills/competencies that you have utilized over the course of your career
(Include skills you may or may not utilize currently):
Designing Learning / Content Development
Managing the Learning Function
Improving Human Performance
Coaching
Delivering / Facilitation Training
Managing Organizational Knowledge
Measuring & Evaluation
Career Planning & Talent Management
Facilitating Organizational Change
e-Learning
6. Of the above competencies: which do you feel are your areas of expertise that you wish to share with a protégé and why?
7. Why did you choose learning/performance improvement as a career?
8. What industries have you served?
9. What interests are you looking for in a protégé?
10. Please provide any additional information you feel may be helpful when matching you to your protégé.
11. Are you able to attend the below listed key events and provide time for communication with your protégé between meetings?
Yes
No
Meeting Requirements
Orientation/Informational meeting: 1 hour prior to March 2008 regular scheduled chapter meeting OR 1 hour prior to April 2008 regular scheduled chapter meeting
Program Matching Event: May 17, 2008
Program Meeting “Progress Check 1”: July 16, 2008, 5:30pm – 8:00pm
Program Meeting “Progress Check 2”: September 17, 2008 5:30 – 8:00pm
Graduation Event (held at regular chapter end of year celebration):
December 2, 2008, 5:30pm – 8:00pm