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Mentor Network
Thank you for volunteering to be a mentor! To help us best match you with your future mentee(s), please fill out the following form.
Important things to note:
- Filling out this form does not automatically match you with a mentee. This form indicates your availability as a mentor for the current academic year.
- The email address here will be used to communicate Mentorship Program updates and will be shared with your mentee in the event you are matched.
Eligibility criteria:
- must be currently established in your professional practice OR be an active student in professional school (i.e. medical school, dental school, etc.)*
* nurses must have BSN at minimum to be a mentor
* Indicates required question
Email
*
Your email
Full Name (First Last)
*
Your answer
Gender
*
Woman
Man
Non-binary
Transgender
Prefer not to disclose
Required
Ethnicity/Race
*
African American/Black
Hispanic/Latinx
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
White, Not Hispanic or Latino
Other:
Required
I identify as...
*
First Generation (a person whose parents did not complete a four-year college degree)
International Medical Graduate (IMG)
Member of the LGBTQIA+/Queer Community
Student from low-income household
Former non-traditional student
None of above
Other:
Required
Where are you located? (City, State)
*
Your answer
Please list all of your degrees obtained to date. "N/A" if not applicable.
*
Your answer
If you are currently a student, please indicate what degree program you are in and at what stage (ex: 3rd year medical student - DO, 2nd year medical student - MD/PhD, 1st year physical therapy school, etc.)
*
Not a student
Other:
Please indicate your mentee preference here (ex: women only, first generation students, students with poor academic history, LGBTQIA+ students, etc.). Type N/A if none.
*
Your answer
How would you like to communicate with your mentee?
*
Virtual only - video conferencing, phone calls, email
In-person only - mentee must be in same or nearby city
Either option works for me
Other:
How many mentees are you willing to work with?
*
1
2
How did you hear about Black Girl White Coat?
*
Instagram
Twitter
YouTube
Linked In
Word of mouth - from a friend or a colleague
Other:
Required
Are you a new or returning Mentor?
*
New Mentor
Returning Mentor
Instagram Handle
Your answer
Twitter Handle
Your answer
Thank you for being a BGWC mentor! If there is any additional information that may assist us in matching you with a mentee, please indicate that here.
Your answer
Send me a copy of my responses.
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