I: Demographic Data

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* Name

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* Phone Number

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* Preferred E-Mail

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* Are you fluent in another language? 

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* Did you have a Mentor in high school?

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* Did you have a Mentor in college? 

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* Did you have a Mentor in graduate school? 

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* Do you have a Mentor now? 

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* Are you retired? 

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* Are you affiliated with a National Professional Medical Organization?

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* Are you part of the MiMentor Community?

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* Do you have current membership with LPOC?

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* Current employer:

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* County of employment:

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* City of employment:

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* Zip code of employment:

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* First generation student?

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* Medical / DO / Graduate School Attended:

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* Year Graduated from Medical / DO / Graduate school:

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* Time off during school:

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* Pathway to Medical School:

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* Name of Undergraduate School:

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* What undergraduate student groups were most influential to you?

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* Do you currently Mentor students?

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* Which region could you support as a mentor?

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* I have previously attended one of the two previous Mentor Advisor Workshops in 2018 or 2019.

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