Academy Mentoring Program Interest Form

The goal of the Academy Mentoring Program (AMP) is to foster relationships within the profession that follow the Student Resident Committee (SRC) mission through networking, interacting, and encouraging relationships. This program pairs young professionals with mentors on an annual cycle and are open to ALL Academy members.

To be considered eligible for enrollment, please complete the virtual interest form below to start the process. Detailed instructions will be sent to you in a separate email outlining the next steps for enrollment. Enrollment will run from January 1 to March 1.  Pairings will be distributed four weeks after enrollment has been completed. The AMP will begin on April 1 and close on December 31. 

If you have any questions, concerns, or comments, please contact the Academy Mentoring Program at

Thank you,

Nia B. Abdul-Malik, MBA
Academy Council, Committee & Project Specialist

* 1. First Name

* 2. Last Name

* 3. Full Credentials (please enter n/a if not applicable)

* 4. Email Address

* 5. Contact Number

* 6. Are you an Academy Member?

* 7. Do you hold a Free OLC Account?