Canadian Association

of Nigerian Physicians

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1. First Name

2. Last Name

3. City

4. Province

5. Email

6. Profession

7. Specialty

8. What is your preferred format for meetings?

Online Video ( Zoom, Skype, FaceTime etc.)

Emails/Texts

Phone calls

In-Person

Other

9. In one word or short phrase what inspired you to become a mentor?

10. How many individuals would you like to mentor?

11. Tell us a bit about yourself. What would you like the mentee to know about you? (2-4 sentences)

12. Is there anything else you would like to share with regards to being matched with a mentee?

How did you learn about our program

Our Website

Social Media

Email

Friend or colleague

Other

Thanks for submitting!