Pre-Med Mentoring Program 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.

Sex *

Male Female

E-mail *

Phone Number *

Area Code Phone Number

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

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?

Yes No No preference

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

Male Female 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?