Doctors Manitoba | Mentor 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.

I am a(n) *

First Name *

Last Name *

Email *

Cell Phone Number *

Pronoun(s) *

They/Them

She/Her

He/Him

Language(s) spoken *

Hometown/Region/First Nation *

How long have you been practicing? *

What year of residency are you in?

Please indicate your PG Level

In which region do you practice? *

Other (please indicate location)

What is your specialty? *

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 being a mentor? *

Is there anything else we should know about you?

Have you previously participated in the mentorship program? *

Yes

As part of the mentorship redevelopment we will be encouraging mentors to complimentary PLI Courses offered jointly with Doctors Manitoba and CMA-Joule. More information can be found here

(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

(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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