Medical Student Mentoring Application

Medical Student / Resident Mentoring Program Application

Medical Student / Resident Mentoring Program Application
Full Name*

PrefixFirst NameLast Name
Please read: Canadian Physicians for Life Principles & Values. Failure to read and indicate agreement/disagreement will result in a longer processing time.*

I agree with Canadian Physicians for Life’s Statement of Principles. *CPL members donate funds to facilitate the mentoring of medical students.I am not in agreement with Canadian Physicians for Life’s Statement of Principles.
Sex*

MaleFemale
E-mail*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Medical School Currently Attending*
Anticipated Grad Year
Please tell us anything you think is important to know about you and your medical school/residency journey. This could include details like you're an international student, you applied multiple times, you entered medicine later on, etc.*
Please tell us a bit more about your MD program. This could include details like program duration, rotations structure, etc.
What specialties are you interested in?
Would you prefer if your mentor were in the same specialty?

YesNoNo preference
Do you prefer a male mentor, a female mentor or do you have no preference?

MaleFemaleNo preference
Do you have any other preferences for your physician mentor (e.g. faith, culture, language, etc.) that you would like us to try to accommodate in particular? We cannot guarantee that all preferences will be met.
What are you hoping to gain from the mentoring program?*
How did you hear about CPL’s Medical Student and Resident Mentoring Program?*
Have you ever attended one of Canadian Physicians for Life’s conferences in the past?*

YesNo
If so, what did you find most valuable from the experience?
Do you have any questions about the med student/resident mentoring program?
Would you like to have your name on our list of med student/resident mentors for pre-med mentorships? This could include helping them with application review, mock interviews, general guidance, etc. We contact every mentor before making a mentorship match*

yesno
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Medical Student / Resident Mentoring Program Application

Medical Student / Resident Mentoring Program Application