POFPS Mentor Program Application

September 2021 - August 2022

Make connections. Make a friend. Make a difference
POFPS’s Mentor Program facilitates meaningful partnerships amongst attendings, residents and medical students throughout the year. Because goals and dreams can change throughout one’s career, participants in the mentor program can be a mentor, mentee or both.

Question Title

* 1. Address

Name *

Address (optional)

City/Town

State/Province

ZIP/Postal Code

Email Address *

Phone Number *

Question Title

* 2. Do you wish to be:

Mentor

Mentee

Both

Question Title

* 3. What best describes your current place in medicine?

Medical student

Resident

< 5 years in practice

> 5 years in practice

Question Title

* 4. What Medical School did you graduate from? What year?

Question Title

* 5. What Residency Program did you complete? What year?

Question Title

* 6. What is your current or planned practice setting/type?

Question Title

* 7. What aspects of medicine interest you most? (Check all that apply)

Clinical

Education

Research

Advocacy

Other:

Question Title

* 8. How would you prefer to communicate with your mentor/mentee? (5 most - 1 least)

Zoom/Skype/FaceTime

Phone

Text

In person

POFPS Mentor Program Application

September 2021 - August 2022

Question Title

* 1. Address

Question Title

* 2. Do you wish to be:

Question Title

* 3. What best describes your current place in medicine?

Question Title

* 4. What Medical School did you graduate from? What year?

Question Title

* 5. What Residency Program did you complete? What year?

Question Title

* 6. What is your current or planned practice setting/type?

Question Title

* 7. What aspects of medicine interest you most? (Check all that apply)

Question Title

* 8. How would you prefer to communicate with your mentor/mentee? (5 most - 1 least)

Question Title

* 9. Is there any particular area of guidance or support you are hoping for with the mentor program?

Question Title

* 10. What do you want your mentor/mentee relationship to look like?

Question Title

* 11. Do you have anyone in mind as a mentor or mentee that you would like to be paired up with?