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Mentorship Registration for Residents — Mentorship Program

Mentorship Registration for Residents — 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.

Please note that while we ask for some demographic information, the information you indicate as being a priority for your mentor will be our priority in creating your match.

First Name *

Last Name *

Email *

Cell Phone Number *

Pronoun(s) *

They/Them

She/Her

He/Him

Language(s) spoken *

Hometown/Region/First Nation *

What year of your residency are you in? *

What is your specialty? *

In which region do you practice? *

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 and having a mentor? *

Is there anything else we should know about you?

Have you previously participated in the mentorship program? *

Yes

Were you a mentor or a mentee?

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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Mentorship Registration for Residents — Mentorship Program