Network Membership, Mentor Application & Onboarding Checklist
Full Name:
Preferred Name:
Professional Degree (MD/DO/PA/NP):
Employer/Practice Name:
Work Address:
Mobile Phone Number:
Format: (000) 000-0000.
Office Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
What is your medical specialty?
Professional Background (Brief Bio or Resume Summary):
Who invited you to join the network?:
Preferred Method of Communication by the Network (not students):
Phone
Email
Text
Other
Volunteer Opportunities (multiple answers allowed):
Program Faculty (2 in-person Saturday mornings + 1 virtual session/year)
Virtual Physician Roundtable discussing specialty (1x/year)
Mentor for the academic year (variable)
Shadowing opportunities (variable)
Career Day for local school
Health Fair
Other
Are you interested in being included in our online physician directory (only professional information included)?
Yes
No
Availability (Preferred days/times for mentoring sessions):
Are you willing to commit to mentoring a student for the full academic year?
Yes
No
Do you consent to a background check (if required by a school)?
Yes
No
Mentor Signature:
Date:
-
Month
-
Day
Year
Date
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MENTOR ONBOARDING CHECKLIST
Please complete the following prior to starting mentorship:
Submit completed Mentor Application
Attend virtual orientation session
Complete background check (if required)
Review and sign Mentor Code of Conduct
Review FP3 Program Overview and Guidelines
Confirm preferred communication method with mentee
Set initial goals and expectations with mentee
Schedule first mentoring session
Agree to an end-of-year evaluation form completion
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