ACMT Mentorship Program: Apply to be a Mentee

Thank you for your interest in the ACMT Mentorship Program!

Please complete the following form to help us match you with a mentor who aligns with your goals, interests, and needs.

Personal Information

Name*

Email*

Cell Phone*

Phone

Current Position/Title

Institution/Organization:

Years of Experience in Medical Toxicology:

Select all that apply*

Are there specific skills or areas of knowledge you'd like to develop through this mentorship?

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What qualities are you looking for in a mentor?

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How would you prefer to meet with your mentor?

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How often would you prefer to meet with your mentor?

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Time Zone

Do you identify with any underrepresented groups?

Would you prefer a mentor who also identifies with a similar group?

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If yes, would you prefer a mentor who also identifies with a similar group?

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Where are you currently practicing?

(Location: City, State, Country)

Do you prefer a mentor from your geographic region or are you open to someone outside your area?

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What length of time are you willing to commit to this mentorship?

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Is there any additional information that would help us find your ideal mentor?

(e.g., specific challenges you're facing, preferred mentor characteristics, etc.)

Send me a copy of my responses