Mentee Intake Form 2016-2017

This form is for students who want to be assigned a virtual mentor.

Are you committed to contacting your DiverseMedicine mentor at least one time per month (note, it is your responsibility to reach out to your mentor, not the other way around)?*
About You
Name:*
E-mail:*
Phone:*
-
What is your preferred mode of communication?*
Paste the link to your DiverseMedicine profile page here. (note, you must have a completed DiverseMedicine profile page to be assigned mentor)*
Name of Academic Institution*
Career Level*
What is your specialty of interest?*
Do you consider yourself a traditional or non-traditional prehealth student?*
Are you a member of any of the following organizations (check all that apply)?
How many times did you take the MCAT?*
Do you have children?*
Past Mentoring Experience
Do you currently have a mentor in the healthcare field?*
Are you confident that you know how to successfully build a relationship with a mentor?*
Have you ever had any training or education on how to build a successful relationship with your mentor?*
If you had a DiverseMedicine mentor last year, on a scale of 0 to 10 (0 being not at all beneficial and 10 being invaluably beneficial), how beneficial was your mentor to your future success?*
If you have had a mentor in the past, in what ways has having a mentor benefited you?*
Really getting to know you!  This information will be given to your mentor.
Tell us a little bit about your childhood and upbringing.*
Describe the most challenging aspect of for you as a prehealth student (e.g. knowing the right classes to take, studying for the MCAT, etc).*
What are you looking for in a virtual mentor?*
Wrapping Things Up!
I have uploaded an appropriate profile photo. I understand that I will not be assigned a mentor without a profile photo.*
I have saved the date of September 19th at 7pm on my calendar to log in to the DiverseMedicine Mentee Orientation webinar (details will be emailed to you). I understand that logging in to this webinar is mandatory in order for me to be assigned a mentor.
To the best of my knowledge, the information entered in this form is accurate. I understand that all DiverseMedicine mentors are volunteers and I will respect the time they generously offer to guide me to success. I understand that it is my responsibility to reach out to my mentor once per month. Finally, I understand that the advice and guidance given to me by my assigned mentor is the opinion of that individual and not that of DiverseMedicine as an organization.*