SPEED MENTORING AT PHM 2018

Sunday, July 22nd
7:00 - 8:30 AM

Mentee Registration Form

* Required Fields


1. General information

*First Name
*Last Name
*Email
*Organization
*Title
*Cell Phone (for on-site communication)

2. Are you an APA member?

Yes
No

*3. Please select your top three choices as a mentee with 1 = highest and 3 = lowest.

Advocacy, Policy and Public Health 1. 2. 3.
Research in PHM 1. 2. 3.
Career Development and Transition 1. 2. 3.
Leadership Skills 1. 2. 3.
Community-Engagement 1. 2. 3.
Quality Improvement 1. 2. 3.
Educational Scholarships/Teaching Skills Development 1. 2. 3.
Work-Life Balance 1. 2. 3.

4. Completion year or anticipated completion date for:

Residency           
Fellowship, if applicable

*5. Please upload your CV.


The APA Board has made a commitment to increasing diversity and inclusiveness in all of our venues. In that spirit, the Speed Mentoring Committee would appreciate your telling us:

6. Do you identify as an under-represented minority?

Yes
No

7. Please note your ethnicity:


8. Have you participated in the Speed Mentoring Event in the past?

Yes
No

9. Do you have any dietary restrictions? If yes, please describe.



*10. This is a very popular session. Due to the overwhelming number of applicants, we have a waiting list. If you do not arrive at least 15 minutes prior to the start of the event, you will forfeit your place and we will begin accepting people from the waiting list. By clicking yes below, you are agreeing to the terms of our event.

Yes
No

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