2018 Annual Conference

Pre-Med Mentor Application
PRE-MED STUDENT PROGRAM FRAMEWORK

The CPL pre-med mentoring program provides resources through the learning platform, yearly conference and interaction with CPL member medical students.
PLEASE NOTE: any information you provide CPL on this form is confidential and will only be viewed for the purposes of admitting you to the program and matching you with a mentor.
Full Name *

Prefix First Name Last Name
Please read: Canadian Physicians for Life Statement of Principles *

I agree with Canadian Physicians for Life’s Statement of Principles. *CPL members donate funds to facilitate the mentoring of pre-med students. I am not in agreement with Canadian Physicians for Life’s Statement of Principles.
University Currently Attending
Grad Year
Sex *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail *
How did you hear about CPL’s Pre-Med Mentoring Program? *
What are you hoping to gain from the pre-med mentoring program?
Should be Empty:

Pre-Med Mentor Application