Mentor Interest - Physician Form
Name
*
First Name
Last Name
Email
*
example@example.com
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Zip Code
Retired - use NA
Home Zip Code
Age
*
Gender: How do you identify?
*
Man
Non-Binary
Woman
Prefer not to disclose
How would you best describe your race/ethnicity? *Select One or More
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
Prefer not to say
Specialty
*
Medical Group Affiliation
*
Community Clinic or Federally Qualified Healthcare Center
Government Employed
Independent Practice with 1-4 Physicians
Independent Practice with 5-10 Physicians
Independent Practice with 11+ Physicians
Mercy Medical Group
Sutter Medical Group
The Permanente Medical Group - North Valley
The Permanente Medical Group - South Sacramento
UC Davis Medical Group
Vituity
Woodland Clinic Medical Group
Retired
Other
What type of mentoring opportunity are you interested in? * Choose all that apply
*
One on One Mentor, 5 Month Commitment
Group Mentoring event
Mock Interviews
Future of Medicine Spring Break Job Shadowing Program, 4 Day Commitment
Future of Medicine Summer Job Shadowing Program, Varies 1 Day - 8 Days
Future of Medicine Summer Program, Virtual Speaker, 1/2 Hour Commitment
What level of education are you interested in mentoring? *Choose all that apply
*
High School Students
Undergraduates
Medical Students
Residents
Physicians new to the area
Early-Career Physicians
Mid-Career Physicians
Other
Submit
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