FCPA Mentorship Group Application

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1. Please check box to confirm that you are an active member of CMDA. If not and would like to become a member, or if you need to pay dues to renew membership, please visit CMDA.org/join to do so. *

Active Member of CMDA

Not a Member

2. Please check the box appropriate to your circumstance: *

I am a PA

I am a PA who graduated < 1 year ago

I am a PA student

3. If you are a PA student, please include expected graduation date:

Full name: *

Current address: *

Phone number: *

Email: *

4. Optional: please provide current school or specialty/workplace:

5. Please check box to confirm that you agree to active participation in this group. Meaning, making an effort to attend Zoom meetings as your schedule permits, as this is the main way that our mentorship group establishes relationships with each other and passes on professional and prayerful support to each other!
*

I agree to have active participation in this group

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