Physician Mentor Application

Physician Mentor Application
Program Overview: How It Works (please read PDF embedded below)

Physician Mentor 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(s) Attended*
Grad Year*
Area(s) of Specialty
Please tell us anything you think is important to know about you and your medical practice. This could include details like you entered medicine later on, teaching, appointments, etc.*
I am interested in (choose all that apply)*

being a mentor for a medical student or residentproviding a rotation opportunity for medical students
Would you prefer if your student mentee were in in the same specialty?

YesNoNo preference
Do you prefer a male mentee, a female mentee 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? If you have more than one, please rank them in order of priority. We will make every effort to accommodate preferences but do not guarantee all will be met.
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 being a physician mentor to students in our Medical Student/Resident Mentoring Program?
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