Name
*
First Name
Last Name
Preferred Pronouns
Division
*
Academic Rank
Please Select
Professor
Associate Professor
Assistant Professor
Instructor
Adjunct
Other
Medical School You Attended
*
Residency Program Where You Trained
*
Fellowship (subspecialty and where you trained)
Other Degrees
Other Experiences
Career Niche/Focus
*
health equity, quality improvement, obesity, endocrinology, etc
Please list your projects that are open for resident participation
Outside Interests
Please indicate whether you'd like to be a career/life mentor, a project mentor, or both
I'd like to be a career/life mentor
I'd like to be a project mentor
I'd like to be a both a career/life & project mentor
I'd like to be a DEI mentor
I am interested in being a mentor for (select all that apply):
*
Career/life mentor
Community and Belonging
Scholarly Projects
IMG Mentor
Please list the resident(s) and the projects you are currently working on
To help mentees understand how better to find academic alignment and mentorship please consider sharing a copy of your academic portfolio, CV or biosketch, or paragraph description of research interests
Browse Files
Cancel
of
Attach a picture of your choice. If you do not attach one, we will use your faculty photo.
Browse Files
Cancel
of
Submit
Should be Empty: