MOA/UNECOM Mentor Program - Oesteopathic Pysician Application

	* - Indicates a required field
*	Name:
*	Address:
*	City:
*	State:
*	Zip:
	E-mail address:
Telephone
*	Work:
	Home:
	Cell:
	Preferred Contact Day:
	Preferred Contact Method:
	Medical School:
	Year Graduated:
	Specialty(s):
	Do you prefer to mentor students/interns/residents in this specialty? Yes No
	Are you willing to mentor students interested in another specialty? Yes No
	How many are you willing to mentor at any given time?
	What is your hometown? State?
	Were ther any unique circumstances in your life during your training that would give you insight into the needs of your student(s)? (Married, children, previous occupation)

	Please list any clubs or organizations you were involved with at medical school.

	Please list any clubs or organizations you are involved with now (professional and non-professional).

	What special interests do you have outside of medicine that would help us match you with a student?

	What makes this project something you would like to be involved in?

	Do you require any special accomodations (interpreter, hearing impaired, materials in special formats)?