Crohn's & Colitis Foundation Women in IBD Leadership Program -- Mentor/Sponsor Application

Crohn's & Colitis Foundation Women in IBD Leadership Program

The Crohn's & Colitis Foundation Women in IBD Leadership Program is a unique opportunity for mid-career female gastroenterologists to participate in high-level leadership education and be partnered with a mentor/sponsor. This is a unique opportunity to mentor someone to assist them in finding a career sponsor, or serving as their career sponsor.

We are seeking sponsors or mentors that can assist program participants by serving as a sponsor or with finding a sponsor. Please complete this application if you are interested in serving in such a role. Applications are to be submitted by November 30, 2021.

Sponsors/mentors must be able to:

--Attend a special event for this program being held in conjunction with DDW 2022.

--Engage with their mentee throughout the year.

--Serve as a mentor who can assist in finding a sponsor or serve as a sponsor

A $1,000 travel stipend will be awarded to each mentor/sponsor.

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* 1. Please provide your contact information

Name

Org/Institution

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Assistant name, email and phone number (if applicable)

Name

Email Address

Phone Number

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* 3. Gender

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* 4. Race and Ethnicity (please select all that you identify with)

American Indian or Alaska Native

Asian or Asian American

Black or African American

Multi-racial

Native Hawaiian or Other Pacific Islander

White

Hispanic/Latino

Not Hispanic/Latino

Other (please specify)

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* 5. Degrees

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* 6. How many years are you post-training?

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* 7. In what professional activities do you spend your time? (please select all that apply)

Adult patient care

Pediatric patient care

Basic research

Translational research

Clinical research

Education/training

Administration

Other (please specify)

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* 8. Practice description (please select only one)

Academic/University Proactice

Private Practice

Accountable Care Organization/Managed Care Organization

Other (please specify)

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* 9. Are you a current Professional Member of the Crohn's & Colitis Foundation?

Yes

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* 10. In order to participate in this program you must be able to attend a special event at DDW 2022. Do you believe you will be able to attend?

Yes

Other (please specify)

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* 11. In order to participate in this program you must be able to serve as a sponsor or assist your mentee in finding a sponsor. Are you able to:

Serve as a sponsor

Assist mentee in finding a sponsor

Comments

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* 12. Mentors/sponsors will receive a $1,000 travel stipend in order to attend DDW 2022. Are you able to receive a travel stipend?

Yes

Other (please specify)

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* 13. Please tell us why you are interested in participating in this program.

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* 14. Although, we are asking you to serve as a sponsor or as a mentor who can assist a program participant in finding a sponsor, we are interested in also matching mentors and sponsors in other types of support. What other types of mentor support are you most interested in providing? Rank the options or select n/a. (Please rank using 1 as your highest preference, 2 as your second highest, etc.)

Academic

N/A

Research

N/A

Private Practice

N/A

Clinical educator

N/A

Industry

N/A

Time management

N/A

Academic writing

N/A

Building a clinic

N/A

Other

N/A

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* 15. Please tell us a little bit about yourself and your hobbies/interests.

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* 16. Is there anything else you would like to share regarding being matched with a mentee?

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* 17. How did you hear about this program?

Email blast

Personal email

Newsletter

Doximity

Twitter

Website

Search Engine

Other (please specify)

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A special thank you to our sponsor!

The Foundation’s Women in IBD Leadership Program was made possible in part by, AbbVie.

<strong>A special thank you to our sponsor!</strong><br><br><strong>The Foundation’s Women in IBD Leadership Program was made possible in part by, AbbVie.</strong>

Please contact Lisa Axisa at laxisa@crohnscolitsifoundation.org if you have any questions.

Crohn's & Colitis Foundation Women in IBD Leadership Program -- Mentor/Sponsor Application