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.*

Sex*

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?*

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