Physician Mentor Application

Full Name

PrefixFirst NameLast Name

Please read: Canadian Physicians for Life Principles & Values. Failure to do so may lead to complications in the application process. Thank you.

Sex

E-mail

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Medical School(s) Attended

Grad Year

Area(s) of Specialty

Please tell us anything you think is important to know about you and your medical practice. This could include details like your affiliation with CFCPS, teaching, appointments, etc.

I am interested in (choose all that apply)

Would you prefer if your student mentee were in the same specialty?

Do you prefer a male mentee, a female mentee or do you have no preference?

Do you have any other preferences for your physician mentor (e.g. faith, culture, language, etc.) that you would like us to try to accommodate in particular? If you have more than one, please rank them in order of priority. We will make every effort to accommodate preferences but do not guarantee all will be met.

Have you ever attended one of Canadian Physicians for Life’s conferences in the past?

If so, what did you find most valuable from the experience?

Have you ever attended one of the Canadian Federation of Catholic Physicians & Society's conferences in the past?

If so, what did you find most valuable from the experience?

Do you have any questions about being a physician mentor to students in our Medical Student/Resident Mentoring Program?