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The Center for Future Health Professionals
Dedicated to guiding future health professionals

Mentee Registration

Thank you for your interest in the Future Health Professional Club mentoring program. You must be at least 18 years of age to register. At this time, only the Pediatric and Hospitalist faculty are serving as mentors and in a few months the program will be expanded to included other deparments and allied healthcare fields. To participate in the mentoring program, please fill out and submit your personal profile below. Prior to registering, please see the requirements for different programs offered: online mentorship, tag alongs and research.Almost all fields are required for registration, however, only your name and e-mail address will be released to the mentor. Other information is for in-office use and matching purposes. We cannot guarantee all applicants will be matched.

Please click here to withdraw your participation.

Personal Information
First Name:
Last Name :
Date of Birth* (mm/dd/yy):
* Applicants must be at least 18 years of age to register.
Ethnic Background (Optional)

Current Address
Address:
City:
State:
Zip/Postal Code:
Phone:
E-Mail Address:
(Matching results and notices will be sent to this e-mail address)
School Name and Address
Name:
Street:
City:
State:
Zip/Postal Code:
Phone:
Other Information About You:
Level of education:
*2nd-4th Medical students who sign up as a mentee should sign up as a mentor.
Degree:
Major:
Degree Date:
GPA (for undergraduates):
Which mentorship method are you interested in? (Can choose more than one option)



Area of interest:
Medicine-Area of Interest:
 Select from list: 
(CTRL + Click to select multiple)
Your Subspecialty Preference (Optional) Select from list: 
(CTRL + Click to select multiple)
Additional/Other:  
Mentor Preference:
Preferred Mentor's Name(s) (Optional):
First Choice:  
Second Choice:  
Third Choice:  
What do you expect from this program (Optional)?
 

The Center for Future Health Professionals
University of California, Irvine Health Affairs
Behnoosh Afghani, MD
© 2007 The Regents of the University of California.
All Rights Reserved.
Last Updated: May 04, 2011

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