The code block below illustrates how one might use # and // as comments in your logic and calculations.

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UT Southwestern Housestaff Mentoring Network Registration

Returning?

A A A

Thank you for your interest in becoming a volunteer faculty mentor. Please complete this registration form. Your submitted information will be posted on our office's website to inform housestaff (interns, residents, and fellows). If you have any questions, please email us!

First Name

* must provide value

Last Name

* must provide value

Please provide your preferred email.

* must provide value

If you have an administrator or calendar keeper, please provide his/her first and last name.

If applicable, please provide your administrator/calendar keeper's email.

Please provide your preferred contact phone number.

Please select how mentees may reach you:

* must provide value

admin/calendar keeper

phone number

In which of these professional development or interest areas do you feel comfortable in providing guidance? Select all that apply.

* must provide value

Developing a Research Career

Diversity Guidance

Family and Childcare as a Physician

Leadership Training

LGBTQ+ Topics

Patient Care in the Era of COVID-19

Religion in Medicine

Single-Parenting as a Physician

Specialty Specific Advice

Wellness

Women's Topics

If applicable, please list any additional career development experiences or areas of interest in which you are able to provide mentorship.

Please provide a brief (200 words or less) biography about yourself. Your bio should focus on items of interest to a potential mentee who is searching for a mentor to match his/her needs. For example, your bio may describe any past mentoring experiences and skills you have in relation to your selected area(s) of interest. In addition, you may describe where you are originally from, what motivates you to be in academic medicine, why you are interested in being a mentor, any special mentoring topics that interest you, as well as hobbies or fun facts that you are willing to share.

* must provide value

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Optional - You may upload a preferred high quality, professional, photo of yourself to be posted on the website. If a photo is not provided we will use an existing web photo.

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