Veterinarian participation form

This registration form is to enable us to match veterinarians with students to create mentoring partnerships. We will try to match you with a student or students interested in the field of medicine you practice and in the area of Illinois or other part of the country where you are located.

* 1. What is your first name?

* 2. What is your last name?

* 3. What is your hospital name and address?

* 4. What is your email address?

* 5. What type of medicine do you practice?

* 6. Please list any board certification or specialty interest (surgery, internal medicine, cardiology, rehabilitation, alternative medicine, etc.).

* 7. In what ISVMA region of the state is your practice located or where do you work?
If outside Illinois, please skip this question.

* 8. If your practice is located or you work outside of Illinois, in what region of the country are you located?

* 9. How many students would you be willing to mentor?

* 10. We recommend that you not request a student partner whom you already know well. If you still have a specific request for a student partner, list the name below.

* 11. If you know other veterinarians who might be interested in participating in this program or would serve as good partners, please list their names and where they work below so that we may contact them.