Building Relationships One Step at a Time. 

Interested in gaining an experienced perspective on applying textbook concepts to real-life situations? Looking to give something back to the profession? Sign up for the Academy Mentoring program and be an intricate part of the future of O&P.

Please submit your application for consideration below. Fields with a * are required.

All applications are due Thursday, March 1, 2018.

* 1. Last Name

* 2. Full Credentials (please enter n/a if not applicable)

* 3. Email Address: (please provide an e-mail address that you check regularly and will not change within the next 12 months)

* 4. Phone (please provide your preferred contact phone number with area code)

* 5. Have you participated in the Academy Mentoring Program in the past?

* 6. I want to participate in this years Academy Mentoring Program as a:

* 7. If in school, when will you or did you graduate? (An approximate day and month are acceptable, please provide an accurate year)

Date / Time

* 8. Which O & P program are you attending or did you attend?

* 9. What is your area of interest (check all that apply)?

* 10. Statement of Interest: Include a brief description of your long-term professional goals. What are the areas where you feel you need development (elaborate on the areas of interest you checked in the question above and/or provide a request for pairing preference)?

This information will be used to pair you in the mentoring program.

* 11. List any hobbies or interests.

* 12. By submitting this application, I agree that (if accepted into the program) I will take initiative, act in a professional manner, and be respectful of time commitments.

If you have any questions or concerns, please contact

Thank you.