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ACRO Mentorship Program
Introduction
Please tell us about your interest in mentoring and/or being mentored.
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1.
Email
2.
First Name
3.
Last Name
4.
In what part of the country do you practice?
Northeast
Midwest
Midatlantic
Southeast/south
West
Other (please specify)
5.
What would you like to become involved in?
Becoming a Mentor
Becoming a Mentee
Both
6.
Please select any national meetings you plan to attend this year. (Check all that apply.)
ASTRO (Chicago, October 24-27, 2021)
ACRO (Fort Lauderdale, March 9-12, 2022)
Other (please specify)
7.
How do you identify your gender?
Cis-female
Cis-male
Trans male/trans man
Trans female/trans woman
Gender non-confirming
Prefer not to disclose
8.
What was your primary position this past year? (Mark only one)
Medical Student
Intern
Resident (PGY2)
Resident (PGY3)
Resident (PGY4)
Resident (PGY5)
Fellow
Junior Faculty - Academic (< 5 years)
Junior Faculty - Private (< 5 years)
Senior Faculty - Academic (> 5 years)
Senior Faculty - Private (> 5 years)
Current Progress,
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