IPPS Mentee Application Form

IPPS Mentee Application

Thank you for your interest in the IPPS Mentor Program!

Requirements for Mentee:

· IPPS membership dues must be current.

· Must be in good standing with your accreditation board (unless a trainee).

· Must hold a valid, unrestricted license in your field (unless a trainee).

· Must be in good standing with your training organization (no history of probationary action).
Personal Information:
Name*

First NameLast Name
Credentials
Dr., MD, etc.
If you are a student, resident, trainee, what is your anticipated year of completion?
Email*
[email protected]
Valid/Preferred Phone Number
(Optional) Please enter a valid phone number.
What type of practice setting do you work or anticipate working? (check all that apply*

RuralUrbanSuburbanAcademic HospitalHospitalPrivate PracticeClinicOther
Do you conduct research?*
If yes, Name of Institution:*
Location of Institution*

CityState / Province

CountryCountry
Brief description of current research interest(s)*
Preferred Mentorship Type? (check all that apply)*

Clinical AdviceCase ConsultationCareer DevelopmentResearch CollaborationOther
What area of specialization would you prefer mentor to have? (check all that apply)*

MaleFemaleTrans/nonbinary conditionsGynecologyPhysical Therapy/Occupational TherapyMental HealthOther
Are there any goals you have developed or information you would like us to consider before matching you with a mentor?*
If none, type N/A
Should be Empty:

	
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Personal Information: