Name

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E-mail Address

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Phone Number

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Where are you at in your training?

Student
Resident

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What type of training are you receiving?

MD
DO
Military
Other:

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What is your gender?

Male
Female

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Which state are you currently training in?

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Which medical school or residency program are you enrolled in?

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When will you complete medical school or residency training?

(YYYY)

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Are you currently involved with the Mentorship program and already paired to a student/mentor? If so please provide the name(s).

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Medical students, what attributes are most important in matching you with a mentor? Residents, where did you attend medical shool? Are you married? Are you pursuing a fellowship or do you have any other unique attributes that you think a student might be interested in learning more about?

MD/DO/Military, Gender, Geographic Preference, Medical School Attended, etc

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Residents, what is the maximum number of mentees that you'd feel comfortable advising?

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Are you an EMRA/ACEP member?

Yes
No
Unsure

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