Resident Mentor Application Name(Required) First Last UAMS Email(Required) Phone(Required)Gender(Required) Female Male Non-binary Prefer not to say Other Gender OtherHometown(Required)PGY Year(Required) PGY-1 PGY-2 PGY-3 Other PGY Other(Required)Residency Site(Required) UAMS North Central – Batesville UAMS Northeast – Jonesboro UAMS Northwest – Fayetteville UAMS Northwest – Rural Training Program UAMS South Central – Pine Bluff UAMS Southwest – Texarkana UAMS West – Fort Smith UAMS Central – Little Rock Tell us a little bit about yourself (hobbies, interests, or future plans)! Feel free to include anything you feel might make a better mentor-mentee pairing.(Required)Do you have any unique life experiences that you can advise students on? (Recently married? Raising a family in residency? Military?)Are there any specific interests you have within the family medicine scope? (E.g. ob/gyn, sports medicine, addiction medicine, gender care, etc)How many mentees are you willing to take on?(Required) 1 2 By selecting yes, you agree that you have read through the requirements for serving as a mentor and agree to meet these requirements for the term you choose to participate.(Required) Yes No By selecting yes, you confirm that you have discussed your participation with and received approval from your program director.(Required) Yes
