Student Membership with Mentorship, Minority Women In Sports Medicine

Name

Email Address *

Phone *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Interested Mentor Profession ( i.e Athletic Trainer, Physical Therapist, Physician, etc.)

Mentorship Interest ( Please Specify)

Are you currently a Graduate Student?

YesNoI am currently a senior undergraduate student, who has been accepted into a graduate program

Current Institution *

Anticipated Graduation Date *

Please let us know why you wish to become apart of the MWISM mentorship program.

Please describe at least (2) personal/professional goals you believe this program can help you achieve.

Can you commit to attending MWISM meetings/workshops? *Events are usually held once per month.

Can you commit to communicating with your Mentor (at least) once per month?

Hobbies/ Interest ( List at least 2)

Additional Information ( i.e specialities, areas of expertise, clinical interest)

Would you like to join the MWISM Directory?

Please attach a short bio.

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Please upload a current photo *

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Yearly Membership Payment ($40) *

Student Membership w/ Mentor Interest