Mentor Application

Please Complete all fields in the form.
First Name *
Last Name: *
Affiliation: *
City *
Country *
Email *
List your main areas of expertise (pediatric, general dermatology, etc.) *
Languages Spoken: *
Will you be able to provide housing? *

Clear Selection
If yes, please explain what type of help with housing.
Will you be able to provide Transportation? *

Clear Selection
What length of time (from 1 to 2 months) can you provide? (For multiple selections, use Ctrl + Click) *
Does your institution charge a fee for an observership/mentorship program? Yes or No. *
If yes, could you describe the fee and let us know if it can be reduced or waived? If no, go to next question.
Please choose your available months in 2023 (Use Ctrl for multiple choices) *
How many young dermatologists can you commit to mentoring in 2023? *
Please choose the type of program you are able to conduct *

Clear Selection
Please list any other Mentors available in your area for co-mentoring.
Please upload your professional headshot or photo for our website.
If you are a new applicant, please give 2 references from ISD.
If you are a new applicant, please upload biosketch or CV
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