Doctors Manitoba | Mentee Application

Inclusion is a key priority of our mentorship program. As part of the registration process, we will be asking a few demographic questions. Please share as much or as little as you are comfortable with.

First Name *

Last Name *

Email *

Cell Phone Number *

Pronoun(s) *

They/Them

She/Her

He/Him

Comments

Language(s) spoken *

Hometown/Region/First Nation *

What year of Residency are you in? *

What is your specialty? *

Where did you obtain your medical training? *

Which IMG program are you currently enrolled in? *

MLPIMG

PRA MB-FB

PRA MB-SP

What is your specialty? *

Other

Please share some personal interests or hobbies *

Please enter at least 1

Please share some professional interests *

Please enter at least 1

Why are you interested in this program? *

Please rank - how important are the following criteria for your mentor? (1 being most important)

Shared interest in a specific medical field

Shared personal interests

Shared demographic (religious or cultural community)

Is there anything else we should know about you?

Is there anything else we should know about your ideal mentor?

Have you previously participated in the program

Yes

(Optional) Do you have children?

Yes

Prefer not to disclose

(Optional) I am a member of a 2SLGBTQIA+ community:

Yes

I would like to provide more information

Clinic Address

(Optional) I identify as a member of the following Racial or Ethnic Group

(Optional) I identify as a member of this spiritual/religious group:

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Mentee Application