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Dr Erin Gorsich
Equity-Driven STEM Mentorship Award 23-24
Application form

Application form

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MENTOR DETAILS

Mentor name * (required)

Mentor position * (required)

Department * (required)

email * (required)

Economic support preference * (required)

Restrictions will apply depending on the grant scheme and/or contract clauses they are associated with

FOR PhD MENTORS

Funding / Sponsor program

If other please specify

Start PhD date

Submission date

End date of student registration (if known)

FOR PDRA AND SENIOR TECHNICIANS MENTORS

Contract details

Position name

Funding organisation

Contract end date

FOR ALL MENTORS

Do you identify as a person from an underrepresented background in STEM (e.g., ethnicity, sexual preference, gender, neurodiverse, economically disadvantaged, etc.)?

.

.

Yes

No

Have you mentored/are you mentoring people from underrepresented background in STEM (e.g., ethnicity, sexual preference, gender, neurodiverse, economically disadvantaged, etc.)?

..

..

Yes

No

Would you like to have additional mentoring support from an external faculty member?

...

...

Yes

No

CASE FOR SUPPORT (MENTORS)

Please briefly explain why you believe promoting equity through mentorship is crucial in science. * (required)

How does this program align with your career development * (required)

MENTEE DETAILS

Mentee name * (required)

Mentee Profile * (required)

Department. * (required)

email. * (required)

Does your mentee identify as a person from an underrepresented background in STEM (e.g., ethnicity, sexual preference, gender, neurodiverse, economically disadvantage, etc.)?

....

....

Yes

No

Members of the triad participation agreement

Please confirm that your mentee has agreed to participate in this internship program

Please confirm that your mentee has agreed to participate in this internship program

Yes, my mentee is aware of this internship program

Please confirm that your line manager/supervisor has agreed for you to participate in this internship program

Please confirm that your line manager/supervisor has agreed for you to participate in this internship program

Yes, my line manager/supervisor is aware of this internship program

Line Manager or Supervisor email * (required)

Consent participation in surveys

Consent participation in surveys

I consent to participating in surveys for project evaluation and potentially being contacted for testimonials that could be used in future case studies

* indicates a required field

Privacy notice

The date and time of your submission, your identity, and the information you have submitted will all be stored, but will only be used to administer the fund, which includes reporting of awarded projects to the funder. All data will be processed in compliance with UK data protection legislation and the University of Warwick Data Protection Policy. Find out more on how Warwick uses your data

The University of Warwick is the Data Controller of any information you have entered on this form and is committed to protecting the rights of individuals in line with Data Protection Legislation. The University's Data Protection webpages provide further information on your rights and how the University processes personal data. If you wish to submit a data subjects rights request, make a complaint or report a suspected personal data breach, please contact the University’s Data Protection Officer by email at infocompliance@warwick.ac.uk.

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Contact us

School of Life Sciences, Gibbet Hill Campus, The University of Warwick, Coventry, CV4 7AL
Email: life dot sciences at warwick dot ac dot uk Tel: +44 (0)24 765 74251

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Page contact: Julie Tod Last revised: Fri 20 Oct 2023

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