Mentee Form CAGS Women in Surgery - Mentee Application Form Name* First Last Address* Street Address City Province Postal Code Email* Phone*Institution* Year Graduated or Anticipating Graduation from Residency* Year Graduated from Fellowship Training (if applicable) Subspecialty Training (if applicable) Current Specialty (if applicable) Select your top three areas for mentorship from the following list*Please hold down the 'Ctrl' or Command key to select multiple areasResearchWork-life balanceObtaining fellowship and/or employmentTransition to practiceClinical practice developmentCareer developmentLeadership developmentIf work-life balance is important to you, please specify below if you are married, single, if you have a young family, want to start a family, etc. so we can match you to an appropriate mentor. (optional) Mentor-matching factorsPlease rank the three matching factors below (geographic location, specialty, mentorship area) as they are most important to you. 1 = most importantGeographic location123Specialty123Mentorship Area123Although we are a primarily female-orientated mentorship program, we encourage inclusivity and collaboration with all our colleagues. We recognize beneficial mentorship transcends gender differences. Some potential mentors may be males. Please indicate if it is important to you that your mentor be a female.* Yes - It is important that I am matched to a female mentor No - I would be open to being matched to a male mentor Please describe what you are looking for in a mentor and what you hope to gain from participating in this program (500 words max).*Please upload an abbreviated CV (no more than three pages)*Max. file size: 256 MB.
