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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. Mentors from various fields in healthcare are available to provide opportunities for the students. 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)
Online mentorship (For more information, please read e-mentoring)
Research opportunities (Only UCI Medical students and undergraduates are eligible for research opportunities. Must satisfy research requirements )
Clinic or Hospital Tag alongs (Must satisfy tag along requirements. At least 2 tag alongs with one mentor is recommended)
Projects: Non-research, not-patient related
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)
Other:  
Mentor Preference:
Mentor Name (Optional):
What do you expect from this program (Optional)?
I certify that I am at least 18 years of age and the information I provided is accurate. I understand that is it is my responsibility to read the instructions provided and comply with all requirements.
 

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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