Mentor Intake Form 2016-2017 Academic Year

Thank you for eMentoring with us!.  We are looking forward to an absolutely amazing mentoring season, during which time, the lives of many pre-health students will be impacted forever thanks to people like you!  We want you to know that we appreciate you donating your time to pay it forward, and that we do our best to make mentoring as simple and enjoyable as we can.  For several years, we have worked hard to develop & implement mentoring strategies that decrease the burden on the mentor while increasing the impact on the mentee.  We think it’s fair to say that our DiverseMedicine eMentoring model does a pretty good job at that!  Again, thank you for being a part of the solution.

-Team DiverseMedicine

Institution at Which You Attend/Work/Practice.*
Specialty of Interest/Practice
Link To Your DiverseMedicine Profile:
State of Residence*
Career Level:*
Mentoring Information
How Many Mentees Can You Mentor This Year?*
Are You Open to Video Chatting With Your Mentee(s)?
Have You Ever Done Virtual (web based) Mentoring Before?*
How Strong of a Mentor Do You Consider Yourself?*
Have You Ever Had Formal Training on How to be a Mentor?
Select All That Apply. I am a member of:
Do You Have Any Specific Requests Pertaining to Your Mentee(s)
Verification & Submission
The information above is accurate to the best of my knowledge. I will do my best to guide my mentee(s) on their journey to success. I understand that a goal of DiverseMedicine is to improve the way that mentoring is done and I agree that de-identified data acquired pertaining to mentoring which I am involved in may be used for academic/research purposes. *