HCMA Member Mentor Registration
Complete this form if you will allow medical students and/or pre-med students to shadow you in your office. The contact information that you provide will be shared with the student/s; you and the student/s will be responsible for arranging the date/time/location of the shadowing opportunity.*
HCMA Member Name
*
First Name
Last Name
MD or DO?
*
Specialty
*
Will you mentor... (check all that apply)
*
Pre-med students
Medical students
How many times per year will you accept students?
*
Maximum number of students per visit:
*
Phone number to coordinate mentoring
*
Please enter a valid phone number.
Email
*
example@example.com
If not you, who will coordinate the mentoring:
Address where mentoring will take place:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional comments/instructions
*Please note:
The physician mentor is responsible for making all appropriate arrangements with his/her practice facility, or wherever the mentoring will take place. Please allow enough time before mentoring to secure the applicable permissions/authorizations.
THANK YOU FOR PARTICIPATING IN THIS PROGRAM!
If you have any questions, please do not hesitate to contact Elke Lubin at the HCMA office: 813.253.0471 or ELubin@hcma.net.
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