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Attending Physician Registration — Mentorship Program

Attending Physician Registration — Mentorship Program

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

Language(s) spoken *

Hometown/Region/First Nation *

How long have you been practicing? *

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 will be provided at the orientation session. To gauge initial interest, please rank the following courses (1 being most important):

Leading with Emotional Intelligence (to be offered in the summer)

Coaching for Excellence (to be offered in the fall)

Physician Leadership Focus (to be offered in the fall)

Have you completed any of these courses through CMA-Joule in the past 5 years?

Yes

If yes, which one(s)?

(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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Attending Physician Registration — Mentorship Program