One Step Ahead Mentoring Program (OSAM) Mentor Registration

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Welcome to the OSAM Program!

Please visit our website for more information if you have questions about the program offerings https://bit.ly/3bF4I5b . If you have any questions, please contact Vaughn Samuel at vaughn.samuel@georgetown.edu.

Email *

Your First Name *

Your Last Name *

Your Georgetown email address *

netid@georgetown.edu

Gender: How do you Identify? *

Male

Female

Non-binary

Required

Prefer to self-describe gender identity? Please describe below.

Please select all that apply that best describes your Race/Ethnicity. *

American Indian/Alaskan Native

Asian

Black or African American

Caucasian/white

Hispanic/Latinx/Spanish

Middle Eastern or North African

Native Hawaiian or other Pacific Islander

I prefer not to respond

Other:

Required

Have you mentored a protégé in previous years for OSAM? If so what years? *

Select whether you are applying to be a mentor for the OSAM Research Track or Medical School Track. *

Research Track

Medical School Track

Clear form

Never submit passwords through Google Forms.

This form was created inside of Georgetown University.

Does this form look suspicious? Report

Forms