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CVCSCCM Mentor Mentee Program (MMP) Sign-up
* Indicates required question
Email
*
Your email
Are you an ACTIVE member of the CVCSCCM chapter? (your membership status will be confirmed prior to the mentor-mentee match)*
*
Yes
No
Title
*
Your answer
Last Name
*
Your answer
First Name
*
Your answer
Middle Name
Your answer
Credentials
*
Your answer
Email
*
Your answer
Email Confirmation
*
Your answer
Institution
Your answer
City
*
Your answer
State
*
Your answer
Job Title
*
Your answer
Area(s) of Practice: Check all that apply
*
Medical
Surgical
Pediatrics
Trauma/Burn
Cardiac
Neuroscience
Mixed Medical/Surgical
Other
Required
Years of experience in critical care practice
*
0-2
2-5
5-10
>10
Are you a trainee (e.g. student, resident)?
*
Yes
No
Would you like to participate as a mentor, mentee, or both?
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Mentee
Mentor
Both
If you would like to participate as a MENTOR, please indicate what areas you would feel comfortable offering mentorship in:
*
Clinical Practice
Research
Professional Development (CV, Networking, etc.)
Management & Leadership
Teaching & Precepting
FCCM Application
Publications & Presentations
Other
Required
If you would like to participate as a MENTEE, please indicate what areas you would like mentorship:
*
Clinical Practice
Research
Professional Development (CV, Networking, etc.)
Management & Leadership
Teaching & Precepting
FCCM Application
Publications & Presentations
Other
Required
Would you like to be paired with someone in your own profession or another profession?
*
My own profession
Interdisciplinary
Same institution
Same state
No preference
Required
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