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Pharmacy Residency Mentor Form
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First and last name *
E-mail address (please check for accuracy)   *
What are your pronouns? *
Required
We are collecting the following information for the purpose : To create a tailored match mentees based on shared life experiences, and to assess our goals for reaching underrepresented applicants. These data will only be seen by Project SHORT committee members. Aggregate counts and percentages may be released, but will not be attached to any identifying information. You may select "prefer not answer" to any questions you do not wish to answer.
In which country do you currently reside? *
In which state do you currently reside? *
Undergraduate university (please include full name, no acronyms) *
What was your undergraduate major(s)? *
What institution did you attend for your PharmD? *
What is your current educational status? *
What areas of interest are you comfortable mentoring for? Check all that apply. *
Required
What institution are you currently at? Institution is broad - can be a university, company, etc. *
Do you identify as any of the following? (Please check all that apply – but do not feel obligated to disclose anything you are not comfortable sharing.) *
Required
What race/ethnicity(ies) do you identify with? Check all that apply. *
Required
What is your gender? *
How would you define your current class? *
Why are you interested in joining the Project SHORT team (please limit to 150 words)? *
How did you hear about us (check all that apply)? *
Required
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