MWC Foundation Mentorship Application

MWC Foundation Mentorship Application
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthday*

MonthDayYear
Date
Current level of Education:*

ElementaryHigh SchoolCollege/UndergraduateGraduateProfessional
Based on your answer above, what grade or year are you at your educational level?*
Ex: 4th grade; Junior; Master's; Doctoral; M1/P1/D1
What field of Healthcare are you entering into?*
Help up to match you!

Statistics show that people, in general, respond better to those of the same gender, race, and ethnic group. The following questions do not impact you being a participant in the Minority White Coat Foundation in any way, but answering will help us to match you with a mentor with similar background and preferences.
Please provide us with more details regarding your professional goal(s) within the field you are entering into:*
Do you consider yourself to be underrepresented in healthcare?*

YesNo
Ethnic Origin:

HispanicNon-HispanicNot Indicated
Race?

Black or African AmericanLatinxAsianNative American or Alaskan Native or Native Hawaiian or Other Pacific IslanderTwo or more races, when one or more are from the categories listed aboveOther
How would you describe your personality?*
How do you prefer communication?*

TextEmailEither is fine!
How often do you want to be in contact with your mentor/tutor?*

Once a WeekTwice a WeekEvery other Week
When you think about communicating with your mentor/tutor, how do you envision the relationship?*

More casual – we will contact each other when we want to talk, knowing that the other person will be available for me when needed.More structured – we will schedule phone calls, e-mails, or personal meetings to ensure we keep up with one another.
Should be Empty: