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* 1. Please enter your name and preferred contact information.

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* 2. Where are you located (City/County)?

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* 3. Are you interested in being a mentor or mentee?

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* 4. What is your current or desired practice setting?

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* 5. What is your current practice group or area of interest?

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* 6. What is the #1 thing you would like to get out of your mentorship relationship?

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* 7. How would you prefer to communicate with your mentor / mentee?

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* 8. Describe your ideal mentor / mentee and/or mentorship relationship.

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* 9. What types of mentorship events, opportunities, and activities would you find most useful?

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* 10. Please feel free to share any other comments, suggestions, or ideas you may have with the YLC Mentorship Committee.

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