Mentor for Life After Residency Survey

If you are interested in becoming a mentor for our attendees of the Life After Residency Program, please complete this brief form.

The full Life After Residency program is scheduled for 12-4PM, but the mentorship session takes place from 3:15-4:00PM. Please see event flyer and agenda at https://aapca1.org/events/ (you are welcome to attend the full program!). During the mentorship session, all mentor-mentee groups will join zoom breakout rooms and mentors will conduct a "speed dating" mock interview followed by one-on-one discussion and questions that the mentee may have. We will supply you with some starter questions. Our goal is to pair 1-2 attendees with each mentor and we hope this mentorship pairing will go beyond this program whereas mentees will be able to reach out to you in the future.

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* 1. Full Name

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* 2. Email Address

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* 3. In what region of the chapter do you primarily practice/reside?
See regions of chapter HERE.

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* 4. Practice Setting:

Community - private (solo or group)

Community - FQHC

Community - County Hospital

Academic setting - Inpatient

Academic setting - Outpatient

Other (please specify):

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* 5. Specialist vs Primary Care (please select one)

Primary Care

Specialist (list what kind below)

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* 6. Where are you in your career?

In practice less than or equal to 10 years

In practice greater than 10 years

Emeritus/Retired

Thank you for becoming a mentor! Closer to the event, we will pair you with a mentee and send you the live event link.

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* 1. Full Name

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* 2. Email Address

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* 3. In what region of the chapter do you primarily practice/reside?See regions of chapter HERE.

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* 4. Practice Setting:

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* 5. Specialist vs Primary Care (please select one)

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* 6. Where are you in your career?

* 3. In what region of the chapter do you primarily practice/reside?
See regions of chapter HERE.