Academy Mentoring Program Application

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.

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* 1. Last Name

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

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

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

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

Yes

If so, what year did you participate?

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

MENTEE: Must be an Academy member in good standing. || May be either a current orthotics/prosthetics resident or student through NCOPE program.

MENTOR-PROTEGE: Must be an Academy member in good standing. || A current orthotics/prosthetics resident through NCOPE program. || An ABC-certified practitioner with any amount of experience who wants to expand knowledge in an area of special interest.

MENTOR: Must be an Academy member in good standing. || Must be an ABC-certified practitioner with minimum 3 years experience.

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* 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

Date

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

Alabama State, College of Health Sciences

CSUDH Orthotic and Prosthetic Education Center

Loma Linda University

Newington Certificate Program

University of Hartford

St. Petersburg College

Florida State University

Georgia Institute of Technology

Northwestern University

Eastern Michigan University

Century College

University of Pittsburgh

University of Texas Southwestern Medical Center

University of Washington

New York University

University of California Los Angeles

Baylor College of Medicine

Other (please specify)

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

Lower Limb Orthotics

Lower Limb Prosthetics

Upper Limb Orthotics

Upper Limb Prosthetics

Gait

Spinal Orthotics

Craniofacial

Research

Business

Legislation, Policy, and Regulation

Other (please specify)

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* 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.

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* 11. List any hobbies or interests.

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* 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 amp@oandp.org.

Thank you.

I Agree

I Disagree

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* 1. Last Name

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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* 11. List any hobbies or interests.

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* 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 amp@oandp.org.Thank you.

* 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 amp@oandp.org.

Thank you.