Mentor Network
Thank you for volunteering to be a mentor! To help us best match you with your future mentee(s), please fill out the following form.

Important things to note:
- Filling out this form does not automatically match you with a mentee. This form indicates your availability as a mentor for the current academic year.
- The email address here will be used to communicate Mentorship Program updates and will be shared with your mentee in the event you are matched.

Eligibility criteria:
- must be currently established in your professional practice OR be an active student in professional school (i.e. medical school, dental school, school of veterinary medicine, etc.)*
* nurses must have BSN at minimum to be a mentor
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Email *
Full Name (First Last) *
Gender *
Ethnicity/Race *
I identify as... *
Where are you located? (City, State) *
Please list all of your degrees obtained to date. "N/A" if not applicable. *
If you are currently a student, please indicate what degree program you are in and at what stage (ex: 3rd year medical student - DO, 2nd year medical student - MD/PhD, 1st year physical therapy school, etc.) *
Please indicate your mentee preference here (ex: women only, first generation students, students with poor academic history, LGBTQIA+ students, etc.). Type N/A if none. *
How would you like to communicate with your mentee? *
How many mentees are you willing to work with? *
How did you hear about Black Girl White Coat? *
Instagram Handle
Twitter Handle
Thank you for being a BGWC mentor! If there is any additional information that may assist us in matching you with a mentee, please indicate that here.
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