Expression of Interest

Please use this Expression of Interest form to indicate your interest in participating in the MICCAI Society Mentorship Program as a mentor or mentee.

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1. Name (Required.)

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2. Position (Required.)

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3. Affiliation (Required.)

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5. In which role would you like to participate in the Mentorship Program? (Required.)

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6. What is your highest degree? (Required.)

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7. Please share any additional information or comments that you would like share to be considered. For any additional questions contact: mentorship@miccai.org (Required.)

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8. Are you a MICCAI Society Member? (Required.)

To become a member of the MICCAI Society, visit www.miccai.org
Term and Conditions

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9. Please confirm that you have read the details regarding your expected duties and management process. (https://miccai.org/index.php/about-miccai/miccai-society-mentorship-program/) (Required.)

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10. Do you agree to have your name published on the MICCAI Society website or in other materials? (Required.)

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