Mentor Application

Physician Mentor Application
Physician Mentor Overview

Physician Mentor Application
Full Name *

Prefix First Name Last Name
Please read: Canadian Physicians for Life Statement of Principles *

I agree with Canadian Physicians for Life’s Statement of Principles. *CPL members donate funds to facilitate the mentoring of medical students. I am not in agreement with Canadian Physicians for Life’s Statement of Principles.
Sex *

Male Female
E-mail *
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Medical School Attended *
Grad Year *
Area(s) of Specialty
Please tell us anything you think is important to know about you and your medical practice. This could include details like you studied other things before or after medicine, you entered medicine later on, etc. *
I am interested in (choose all that apply) *

being a mentor for a medical student or resident providing a rotation opportunity for medical students
Would you prefer if your student mentee were in the same specialty?

Yes No No preference
Do you prefer a male mentee, a female mentee or do you have no preference?

Male Female No preference
Do you have any other preferences for your student mentee (e.g. faith, culture, languages spoken, etc.) that you would like us to try to accommodate? We cannot guarantee that all preferences will be met.
Have you ever attended one of Canadian Physicians for Life’s conferences in the past? *

Yes No
If so, what did you find most valuable from the experience?
Do you have any questions about being a physician mentor to students in our Medical Student/Resident Mentoring Program?
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Physician Mentor Application

Physician Mentor Application