Pre-Med Mentoring Application

Pre-Med Mentoring Program Application
Pre-Med Program Overview

Pre-Med Mentoring Program Application
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*

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 pre-med 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
University/college currently attending*
Expected grad year from current program (yyyy)*
Which academic cycle are you applying for? (yyyy - yyyy)*
Please tell us a bit about your pre-med program (this could include details about duration, co-op, fast-track, 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 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 pre-med mentoring program?*
How did you hear about CPL’s pre-med mentoring program?*
Do you have any questions about the pre-med mentoring program?
Should be Empty:

Pre-Med Mentoring Program Application

Pre-Med Mentoring Program Application