Interest Form for Student Member Mentoring Breakfast

Each year the College provides a networking/mentoring session during our annual meeting specifically geared towards the needs of Medical Student Members. To make this session more effective, the College is interested in learning from you what issues you are confronting as a medical student that you would like to receive advice about. It is not necessary to be an attendee to our annual meeting. This is a general request for information to the broader medical student membership. The information you provide will help shape mentoring programs and provide ideas for new medical student programs.

So that we can fully understand your interests, please provide the following information.

Note: Fields marked with * are required.

Name*:

Email*:

Are you interested in subspecialty info?
Yes
No

If so, please select from the list below the top three you would like to learn more about.

Allergy/Immunoligy
Cardiology
Endocrinology
Gastroenterology
Hematolgoy/Oncology
Infectious Disease
Pulmonary/Critical Care Medicine
Nephrology

Please rate your interest in the following career paths with 1 being the greatest of interest and 4 providing the least interest:

General
Academic
Research
Patient Care
Other, please list:

Have you ever used a Mentor? If yes, please select

Face to face
Online
Other

What characteristics do you feel a Mentor should possess to be effective in guiding medical students?

Have you taken part in medical volunteerism as a medical student? If so, was it:

Domestic
International

Please select the top 2 areas of interest that you have:

Ways to turn research into public work
Grant writing
Training related issues, balancing education and home/family life
Selecting the right Residency Program
Other

Thank you for completing this form.

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