MSDCI National: Mentorship Program (Mentee Interest Form)

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Were you looking for the mentor interest form instead? If so, please click here to be redirected.

Thank you for your interest in being a mentee in MSDCI National's Mentorship program!

What is this mentorship program?

- This program is designed to make a 1:1 connection between a pre-med or medical student with disability and/or chronic illness ("mentees") with a current MSDCI medical student member ("mentors").

- These mentor-mentee connections are being facilitated by MSDCI National. However, the exact nature of the mentor-mentee discussions will be up to you! We recognize that living with a chronic illness and/or disability comes with its unique set of experiences and challenges, and we aim to better support our community members through their journeys navigating medicine.

- Please note that our mentors are volunteering their time for this program, so we ask that mentees do not ask for direct review of their medical school or residency applications, unless it specifically relates to their chronic illness and/or disability. A full set of Community Guidelines for mentees can be found here.

Who can participate? Any current pre-med individuals (people who are currently applying or are considering applying to medical school; this can include undergraduate students, post-baccalaureate students, people in graduate programs, etc.) or current medical students (including those on leave, research years, etc.) who are interested in participating as a mentee (i.e. getting matched 1:1 with a medical student mentor) are welcome to fill out this form!

How does the mentor-mentee matching program work?

1. You fill out this form

2. We send out non-identifiable information about mentees to our group of mentors. This will include any demographic information that you specifically indicate you are comfortable sharing, as well as a brief paragraph that you will submit on this form.

3. We will try our best to match you with a mentor within 8 weeks of your submission of this form. Once a match is made, we will pass on your contact information, for the mentor to reach out to you.

What is the expected timeline? Because we are relying on our mentors to volunteer, we cannot guarantee that we will be able to match you with anyone. However, we will reach out within 8 weeks to update you. If you have not heard an update from us 8 weeks after you have submitted this form, please reach out at mentorship@msdci.org

Whom can I contact if I have questions about this mentorship program? Please reach out to mentorship@msdci.org, and a member of our leadership team (Zak, Kelsey, and/or Amy) will get back to you within 1 week!

Where can I learn more about MSDCI? You can visit our website at www.msdci.org or join our Listserv by emailing msdcinational@gmail.com

Email *

Record my email address with my response

What is your name? *

What is your email address? *

What is your phone number?

What is your preferred method of contact? *

Phone (call)

Phone (text)

Required

Demographic Information

Please note that you are not required to disclose any of your identities. We are collecting this information as part of an ongoing review of this program which is helping us understand which identities our community members hold, so that we can better provide inclusive support and resources.

All of this information will be deidentified (i.e. your name or personal contact information will not be linked to any of these identities) when we conduct our aggregated analysis.

What best describes where you currently are in your educational journey? *

Pre-med student (currently in undergraduate)

Pre-med student (currently in a post-baccalaureate program)

Pre-med student (currently on gap/discovery year, in graduate school, or a "non-traditional" pathway)

Medical student in an MD or DO program (currently taking the pre-clinical curriculum)

Medical student in an MD or DO program (currently in clerkships/clinical rotations)

Medical student in an MD or DO program (currently taking a leave of absence)

Medical student in an MD or DO program (currently in Master's or PhD years)

Other:

What is your college/university (if applicable)?

Do you prefer to have a mentor from your institution?

I prefer to have a mentor from my institution

I have no preference

I do not want to have a mentor from my institution

Clear selection

How would you describe your gender identity? *

Woman

Man

Non-binary

Genderqueer

Prefer not to say

Other:

Required

How would you describe your racial and/or ethnic background? Please check all that apply. *

American Indian, Native American, Indigenous, or Native

Asian or Asian American

Black or African American

Hispanic or Latino/a

Middle Eastern or North African

Native Hawai`ian or Pacific Islander

White

Prefer not to say

Other:

Required

Which of the following disability/chronic illness categories do you identify with? Please check all that apply. *

sensory disabilities (including blindness, deafness, lack of taste, lack of smell, and other sensory conditions)

psychiatric disabilities (such as depression, anxiety, and other mental disorders)

chronic illness, chronic pain, invisible disabilities, and/or undiagnosed conditions

cognitive and intellectual disabilities and other neurodiversity (ADHD, Autism spectrum, dyslexia, Tourette syndrome)

physical disabilities

Required

Which of the following groups or identities, if any, describe you? Please check all that apply. *

We are collecting this information as part of an ongoing review of this program which is helping us understand which identities our community members hold, so that we can better provide inclusive support and resources.

All of this information will be deidentified (i.e. your name or personal contact information will not be linked to any of these identities) when we conduct our aggregated analysis.

Please note: URM is defined by the American Association of Medical Colleges as "racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population". This has historically included individuals who identify as Black, Mexican-American, Native American (American Indian, Alaska Native, and Native Hawaiian), and/or mainland Puerto Rican.

LGBTQIA+

URM (underrepresented in medicine)

First generation in medicine

First generation college student

First generation American/Immigrant

Low income background

Live in or grew up in a rural area

Non-traditional student (entering medical school to make a career change)

Currently a parent

Already have a graduate degree

Military

Non-STEM major

None of the above

Prefer not to respond

Other:

Required

Which of the above identities or pieces of demographic information would you like us to share with your potential mentor?* Please check all that apply.

ONLY the categories you indicate in this question will be shared with your potential mentor. Please feel free to indicate any of the identities from the question above (you can type this in the "Other" category).

*We are asking this question because we recognize that certain identities are important to your experiences, and some people prefer to have a mentor who understands those experiences (if possible).

Gender identity and sexual orientation

Racial and/or ethnic background

Type of disability

Prefer not to respond

Other:

Required

Please write 2-3 sentences about yourself. We will send these to our mentors to help us during the mentor/mentee matching process.

Examples of these "about me blurbs" can be found below:

I use a wheelchair. I am a current senior at XYZ College studying biology and hoping to apply to medical school. I am nervous about what accommodations will be available for me and if it’s even possible to become a doctor.

I am a current M1 struggling with my coursework and feeling overwhelmed. I don’t know if I should disclose my disability to my school or not so I’m looking for advice.

As part of our research to better understand the needs of our community, we are including a few questions below. You are not obligated to answer them, but we would greatly appreciate your help.

There is support in the medical education system for those with my chronic illness or disability.

Strongly agree

Strongly disagree

Clear selection

There is a supportive community that I can be a part of if I choose to pursue medicine.

Strongly agree

Strongly disagree

Clear selection

I feel prepared to apply for medical school.

Note that this question only applies to mentees who are current pre-medical students. If you are already a medical student, please skip this question.

Strongly agree

Strongly disagree

Clear selection

How did you hear about this program? Please check all that apply *

MSDCI National GroupMe

MSDCI National Instagram

MSDCI National Twitter/X

MSDCI National Listserv

MSDCI Chapter at a medical school

Alliance for Disability in Health Care Education (ADHCE)

Disability Advocacy Coalition in Medicine (DAC Med)

Disability in Medicine Mutual Mentorship Program (DM3P)

Docs with Disabilities

Pre-Med American Medical Student Association (PAMSA)

Stanford Medicine Alliance for Disability Inclusion and Equity (SMADIE)

Other:

Required

A copy of your responses will be emailed to .

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Stanford University. Report Abuse

Forms