Copello Fellow Mentorship Form
The Copello Fellowship mentorship program pairs fellows with experienced mentors for intentional, structured conversations during the fellowship year. The goal is to provide support without making the relationship overly prescriptive.
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Primary Location (City, State)
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Credentials & Degrees (e.g. MD, DO, MPH, etc.)
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Practice/Work Setting Experience (Select all that apply)
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Academic Medical Center
Community Hospital/Health System
Non-Profit/Public Health Organization
Government/Policy Institution
Private Practice
Research
Other
Practice Area/Specialty (e.g. Family Medicine, OB/GYN, Cardiology, etc.)
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Please share a brief summary of your advocacy work to help us introduce you to prospective mentees.
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List three qualities that you possess that would make you a good mentor.
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What is one piece of advice or a lesson from your own career that you wished you learned earlier?
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What areas would you particularly enjoy helping a mentee develop? (Select all that apply)
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Advocacy skills
Leadership
Public speaking media
Policy
Organizing/mobilizing
Work-life integration
Building professional networks
Navigating challenging professional situations
Other
What would make this mentoring experience successful for you?
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DFA is committed to developing advocates who can lead with humility, curiosity, collaboration, and courage. How would you help a mentee develop their own leadership voice rather than simply teaching them to approach advocacy the way you do?
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