Mentor Application

Physicians and Medical Students can apply to be mentors with Canadian Physicians for Life

MENTORING FRAMEWORK

The CPL pre-med and medical mentoring program provides resources through the Learning Platform, National Conference and matched one-on-one mentorship with CPL member physicians.

We are also developing a registry of rotation opportunities for our medical students.

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.

Medical School

Area of Specialty

Grad Year

Sex *

Male Female

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number

E-mail *

I am interested in (choose all that apply)

being a mentor for a medical student providing a rotation opportunity for medical students

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?