Student Sign-Up Form
Name
*
First
Last
Email:
*
Phone
*
Current City:
*
Medical School
*
Medical College of Wisconsin
University of Wisconsin
Other
What I hope to gain from a mentoring experience:
*
How far are you willing to travel to meet with your mentor?
*
Up to 10 miles
Up to 30 miles
Up to 60 miles
I will go anywhere
N/A - no transportation
Are you willing to provide WPA with feedback of your experience?
*
Yes
No
Preferences (geographic, discipline, etc)
Submit
Should be Empty: