Mentor Questionnaire
Health Equity and Anti-Racism Team (HEART), the community engagement arm of APTA DC, has developed a pipeline program focused on increasing diversity in the Physical Therapy Profession called the Physical Rehab Exposure Program (PREP).

Thank you for your interest in being a mentor for PREP!  

This questionnaire will help us as we plan for our PREP mentor list.  We will be pairing PREP students up with mentors on a rolling basis as the students indicate interest.


Thank you for your interest! If you have any questions please email heart@aptadc.org.
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Name *
Email address you can be reached at: *
What undergraduate and graduate institutions did you attend?
What career stage are you in currently? *
List any volunteer experience you've had in the last 5 years.
Why do you feel you would be a good mentor for a PREP student?
What are your areas of interest? (Check all that apply)
Do you have a specialties or certifications? Please list them below.
Are you an APTA member?
Clear selection
Are you in any other associations or organizations that may be of interest to a potential mentee?
Are you interested in receiving the HEART newsletter, updates, and opportunities? (We will use the email you provided above.)
Clear selection
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