IAMSE Medical Educator M-REACH Certificate Application
Please complete this form by April 15, 2023. If you have any questions or difficulities submitting the form, please email support@iamse.org for assistance.

The cost for the year-long M-REACH program is $500 for members and $700 for non-members. You will receive an invoice upon approval for the program.
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First and Last Name: *
Email Address: *
Institution (name and country) *
Example: Harvard University, USA
Preferred Address:
Preferred Phone Number: *
What is your current academic title? *
If applicable, please list your administrative title:
Are you currently an IAMSE member? *
Are you planning to attend the 2023 Annual IAMSE Conference in Cancun, Mexico? *
By participating in the IAMSE professional development M-REACH certificate program, what do you hope to achieve? *
Please list 1-2 goals.
Briefly describe past mentoring experience either within IAMSE or in a past/current role: *
Please indicate your availability to present at the 2024 annual conference: *
The program, as planned, will include a project related to mentoring that will foster your ability to apply program content to practice.
Describe your capacity to complete a project with a mentoring focus while in the program: *
Do you have ideas for a project focused on mentoring either as a mentee or mentor? If yes, please describe.
I have reviewed the program description and can commit to virtual didactic sessions that are planned: *
If the above link doesn't work, copy and paste the following URL into your browser: http://www.iamse.org/wp-content/uploads/2023/02/Mentoring-Description-02.2023.pdf
Describe how your home institution will support (time, finances, etc.) your participation in the program:
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