Qualtrics Survey | Qualtrics Experience Management

Black and Latinx Mentor Form:

Thank you for your interest in becoming a mentor for a Stony Brook medical student. Please take a few minutes to complete this form to let us know about yourself. Once we receive your information, we will connect you with one of our outstanding students who is looking for advice concerning your specialty, leadership opportunities and work/life balance.

First Name:

Last Name:

Graduation Year from Renaissance Stony Brook School of Medicine:

Your Specialty:

City:

State:

Hospital Affiliations:

How would you like to be contacted by your mentee?

How often would you like to be contacted by your mentee?

Are you interested in attending Social Events?

Yes
Maybe
No

Are you conducting Research, and if so, what type of research?

Yes
No