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Mentor Application: OMSA Mentorship Program
Mentor Sign Up
Please complete the details below. Providing this information will add you to our mentor database for future mentorship opportunities with a mentee that has similar interests as yourself. Please note, not every mentor is matched with a mentee each year, as it is based on mentee interest.
Filling in this sign up sheet signifies that you consent to being contacted by a member of the Ontario Medical Students Association regarding mentorship involvement.
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* Indicates required question
Email
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Your answer
First and Last Name
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Your answer
What is your clinical specialty?
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Your answer
What is your current level of practice?
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Resident Physician
Physician
What is your city/location of practice?
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Your answer
Is there a university/institution are you affiliated with? If so, please list:
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Your answer
(Optional) Do you identify with any of the following communities? Some students request being matched with physicians with similar backgrounds.
Women in Medicine
Black Physician
Indigenous Physician
Physician with a disability/chronic health illness
Other:
What is your race/ethnicity (African American, East Asian, South East Asian, Indigenous, White/Caucasian, prefer not to answer, and etc.)? We may aim to match you with a student identifying from the same group.
Your answer
Please use this space to provide any additional clinical interests and demographics (e.g. LGBTQ2S+, francophone, etc.) based upon which you would be willing to be matched to a mentee.
Your answer
If you work with any specific populations, please list these here (e.g. LGBTQ+, refugees, Indigenous, etc)
Your answer
Is there any other information you would like us to know?
Your answer
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