Young MD Cultivate

Young MD Mentorship Application 2021

Dear candidate, please take your time in answering this survey. Answer honestly and carefully. Kindly note that this programme targets qualified medical doctors, however, motivated final year medical students may apply. No confirmation will be sent on completion of this survey. Only successful applicants will receive a response in August 2020 where a round of interviews will be conducted before admission into the programme. In the event that you do not receive any communication regarding your application by 1 September 2020, please consider your application unsuccessful.

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* 1. What is your name, surname and rank? (E.g.: student, intern, medical officer)

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* 2. Where are you currently employed? (Final year medical students can state their university here).

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* 3. What is your field of interest? e.g: Urology or Peadiatrics

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* 4. How much time are you willing to avail to the mentorship programme per week?

Uncertain

30 min-1 hour per week

1 - 2 hours per week

2 - 3 hours per week

1 hour every 2 weeks

1 hour per month

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* 5. Why are you the most suitable candidate for the Young MD mentorship programme? (Please ensure your motive and desired outcomes for mentorship are clearly stated in your answer).

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* 6. What sets you apart as a Medical doctor amongst your peers? (Final year students can share what currently sets them apart from their peers).

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* 7. What are your hobbies or interests outside of the medical field?

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* 8. Do you have a gender preference for a mentor?

Female

Male

Both

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* 9. Please list your contact details below.

Email Address

Phone Number

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* 10. Please share a contactable reference for this application

Name and Surname

Email address

Cellphone