2018 Annual Conference

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?
Should be Empty:

Mentor Application