Latino Medical Student Association Southeast Region Mentor Form
Objectives of the LMSA SE Region Mentor/Mentee program:

1) Create connections between Latino residents/attendings and medical students that can help in the process of creating successful future physicians
2) Allow communication and networking between physicians and students all throughout the Southeast region
3) Create a long lasting, meaningful bond between mentor/mentee that is of significant value to all parties involved
Current location where you practice medicine (city, state and hospital and/or university affiliation)
Are you interested in being a mentor to a Latino medical student?
Clear selection
Are you interested in being a mentor to more than one student?
Clear selection
Which form of communication would allow you to best maintain this mentorship for a sustainable period of time?
Please list the preferred method of communication you selected above (include specific email and/or telephone number below)
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