Please enable JavaScript in your browser to complete this form.Please complete this form to the best of your ability to help connect you with a suitable mentorEmail *Please enter a valid email addressFull name *Your answerPreferred email address *Your answerLocation (City, Country) *Your answerHighest degree (e.g., M.D., B.S., Ph.D.) *Current level of education (e.g., medical student, post-doc, fellow, undergraduate) *Specialty, if applicableCurrent training institutionHave you had prior mentors?YesNoDo you have current mentors?YesNoPlease specify the name and affiliation of your current mentor(s)Your answerWhat do you want to achieve from the mentorship program?Basic Research (e.g.,designing a study, developing skills, data analysis)Clinical research (e.g., patient recruitment, study design, funding)Career development- transitioning from training to staff or faculty, areas of interest, and specialty choice and preparednessTraining advice (e.g., navigating residency and applications)Writing skills (e.g., grants, manuscripts, abstracts, personal statement, communication)Personal development (e.g., leadership/negotiation,CV)Please choose the career development focusAcademicHospital-basedPrivate soloPrivate groupGlobal health/AdvocacyPlease estimate the required time to achieve your mentorship goals1-3 months4-6 months7-9 months10-12 monthsNot sureHow frequently would you need to meet with the mentor to reach your goals?WeeklyEvery 2 weeksEvery 3 weeksEvery 4 weeksNot sureHow did you hear about the mentorship program?Social mediaWord of mouthEmail communicationWhat is your preferred mode of communication?In-person, face-to-face (only in the USA)TelephoneE-mailVirtual meetingBiographic questions (Briefly explain your career goals – frame it with 5-10 year goals Limit 1000 characters) *What do you expect from the mentorship program? Limit 1000 characters *Submit
