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IIHC Mentor Application
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Medical Students - Educational Tracks
Introduction to Integrated Health Care
Kaiser Longitudinal Integrated Clerkship (KLIC)
La Salud Permanente Latinx Health Elective
Medical Education & Simulation Elective
Research Elective
SCORE Program
Name
First
Last
Email
Credentials
MD
MD, MPH
MD, PhD
DO
DPM
Other
If "other" credential selected, please specify
What is your specialty?
Sub-specialty if applicable
Main Kaiser facility in which you practice
Do you have an interest in working with specific demographic groups?
Black/African American students
Hispanic/Latinx students
First generation college students
LGBTQA+ students
Veterans
No preference
Other
If "other" please specify
Professional Interests
Personal Interests
Why do you want to be a physician mentor?
I will commit to one hour per month to meet with my mentee virtually.
Yes
No
I understand that I may be matched with mentees who do not share my specific interests.
We will do our best to match mentors with mentees who share similar interest and specialties.
Yes
No
I acknowledge that the above information will be used to help match me with a mentee.
I agree
Medical Students - Educational Tracks
Introduction to Integrated Health Care
Kaiser Longitudinal Integrated Clerkship (KLIC)
La Salud Permanente Latinx Health Elective
Medical Education & Simulation Elective
Research Elective
SCORE Program
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