Mentorship Program Application

Mentorship Program Application
Thank you for your interest in the Academy of Orthopaedic Physical Therapy Mentorship Program. We will be matching student mentees to mentors based on clinical interests or SIG involvement for a 6-month formal mentorship period and hopefully a connection that lasts for years to come.

Selected student mentees will meet their mentors during CSM in Houston, TX, in February. Over the 6 months following CSM, the mentees will be required to communicate monthly with their mentor over the phone, by email, over Teams/Zoom/Skype/Webex, or any other convenient communication method.

Student mentees will also participate in one virtual journal club over the 6-month period to discuss a current research article related to orthopedic physical therapy practice.

Please read the requirements carefully. Answer the questions below so that we may select mentees and pair them with mentors who have similar clinical interests for the best success of the program.

Participants must be:
1. In his or her final year of an accredited DPT program
2. An Academy of Orthopaedic Physical Therapy Member
3. Planning to attend CSM for in person mentorship program option, or:
4. Virtual option: The AOPT will be offering a virtual option for students and mentors unable to attend CSM in person.
Applications must be received by Monday, December 23rd, 2024.
Name

First NameLast Name
APTA ID #:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
PT School:
Year:
Will you be attending CSM in Houston?

YesNo
Would you prefer to participate in the virtual option of the program due to being unable to attend CSM?

YesNo
Interests: Tell us in which area you are interested to receive mentoring (choose 2 only)

Research in OrthopaedicsAcademics/TeachingManual TherapyProfessional Organization Involvement/LeadershipPrivate PracticeOther
If you selected "Other" above, please explain below:
Special Interest Groups: Are you interested in mentorship through a specific SIG? (choose 1 only)

Animal PT SIGFoot and Ankle SIGOccupational Health SIGPain SIGPerforming Arts SIGImaging SIGResidency/Fellowship SIGNot applicable
Short Essay and Goals: In 500 words or less, please summarize why you would like to be part of this program and what you expect to accomplish at the completion of the 6-month membership program.
Please list 3 specific goals of your mentorship experience:
Agreement and Signature:By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a mentee, I will complete the program including all communication and projects required.
Enter your name in this field, affirming the validity of your entries in this form.
Date:
Our Policy:
It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.

Thank you for completing this application form and for your interest in receiving mentorship by one of the mentors of the Academy of Orthopaedic Physical Therapy, APTA, Inc.
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