MOLA '21-'22 Mentorship Mentee Application

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Thank you for your interest in becoming a MOLA Mentee!

We aim to serve the interests, aptitudes, and progress of Latinx students, like you, at every point in their professional development.

Location of Events:
Zoom until stated otherwise.

Benefits of being a MOLA Mentee:
• Boost your network
• Gain practical advice, encouragement & support
• Identify goals and establish a sense of direction
• Increase your social and academic confidence to make empowered decisions
• Develop your intrapersonal & interpersonal skills
• Recommendation letters
• Free MOLA Latino Health Symposium entrance
• MOLA Mentorship Program Certificate

MOLA Mentee Commitment:
*App Due August 28 11:59 PM CST NO EXCEPTIONS
• Respond to program communications (email/text). The MOLA Mentorship Program uses email as the primary form of communication.
• To remain in the program, mentees are required to participate in 75% of MOLA’s mentorship programming. The seventy-five percent would be attending at least 8 of the 12 events per calendar year (there is one event per month).
-Mentees are required to submit the quarterly check-in form

Email *

Full name and pronouns: *

Email: *

Phone Number *

Zip Code of your current residence *

Name of High School and graduation year:

Name of undergraduate institution, graduation year, and degree acquired: (If you have graduated from undergraduate)

Name of Graduate institution, graduation year, and degree acquired: (If you have completed a non-MD/DO graduate degree)

Name of Medical School, graduation year, and degree(s) acquired: (If you have completed an MD, DO, or MD/DO-PhD)

During 2021-2022 I will be in: *

During 2021-2022 I will be considered a: *

The institution I currently attend/ am affiliated with: *

What is your current GPA (in the program you are currently enrolled in):

Check all that are applicable: *

I am primarily affiliated with MOLA Chicago AND have signed up as an official member

I am primarily affiliated with MOLA Chicago, but am not a member

I am primarily affiliated with MOLA Wisconsin

I am primarily affiliated with Southern Illinois University

I am primarily affiliated with Northeastern Illinois University

Other:

Required

I am currently interested in: *

Medical School

Dental School

Nursing School

Physical Therapy School

Pharmacy School

Physician Assistant School

Masters in Public Health

Emergency Medical Training (EMT)

Required

I plan to apply to health professional school during: *

2021-2022 Application Cycle

2022-2023 Application Cycle

2023-2024 Application Cycle

Required

I am the first in my family to addend: *

College

Medical School

Not Applicable

Required

The race/ethnicity I identify with: *

Languages that I speak and at what level (eg. Spanish, conversationally fluent):

I am interested in: *

Being a Mentee

Being a Mentor (Separate Application)

Being in the mentorship program without a mentor by attending the Mentorship Lecture Series

Giving a lecture as a part of the Mentorship Lecture Series

Receiving emails about events, scholarships, opportunities relevant to me

Required

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