Student Mentee Application Name(Required) First Last UAMS Email(Required) Phone(Required)Gender(Required) Female Male Non-binary Prefer not to say Other Gender OtherHometown(Required)Class(Required) M2 M3 Medical School Campus(Required) UAMS Main Campus – Little Rock UAMS Northwest Campus – Fayetteville 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 we should consider? (Recently married? Raising a family in residency? Military?)Are you specifically interested in any of the following?(Required) Rural Suburban Urban No preference Are there any specific interests you have within the family medicine scope? (E.g. ob/gyn, sports medicine, addiction medicine, gender care, etc.)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
