Mentorship Application – Physician Mentorship Application - Physician Name* First Last Phone*Email* Preferred mode of contactEmailPhoneDoesn't MatterWho would be the point of contact at your office/clinic for scheduling?Languages other than EnglishWhere were you born?In which city/community do you practice (list all that apply)?In which clinic or hospital do you currently practice (list all that apply)?Where did you get your medical degree?Where did you do your residency?List any education other than your undergrad degree or medical degreeHow many years have you been in practice since completion of training?* 5 years or less 6-10 11-20 20+ What is your specialty (eg. family medicine, neurology, etc.). List all that apply*What proportion of your practice is dedicated to research, if any?Do you have any notable hobbies or interests?How many medical students are you willing to mentor?*1 or 23 or 45+Are you willing to allow a medical student to job shadow you for a period of time?*YesNoDo you have any other significant or unique experiences, identifications or qualities?Some Mentors and Students have interests in family-related topics such as parenthood. At your option, feel free to describe your circumstances in that regard.Why do you want to be a mentor?Acknowledgement* I acknowledge that I have reviewed the Doctors Manitoba Mentorship Program Code of Contact and that I understand and will abide by it.