MENTOR REGISTRATION Name* First Last Address* City* State* Zip* Email* Work PhoneCell PhonePREFERRED CONTACT METHOD* Phone Text Email FaceBook CURRENT EXPERIENCE LEVEL* Resident Fellow YPS Over 10 years in practice Current Specialty* PRACTICE TYPE* Private Practice Employed Academic WHICH MENTORSHIP ACTIVITIES ARE YOU INTERESTED IN PARTICIPATING IN?* Mentorship at Winter Medical Conference Mentorship at National Conference Telephone or Email Advice Shadowing Opportunities Research Assistance Interview Training CV/Cover Letter Review Specialty Choice Advice Test Taking Other IF YOU ANSWERED "OTHER" FOR THE ABOVE QUESTION, PLEASE PROVIDE FURTHER DETAILS.*ARE YOU INTERESTED IN BEING A PRECEPTOR IN AN OFFICIAL OBSERVORSHIP (1 MONTH PERIOD WITH $1,000 STIPEND)?* Yes No Paid Observership Preceptor Link OBSERVER REGISTRATION
