MS Mentorship Forum Application Form

MS MENTORSHIP FORUM APPLICATION 2025

Deadline: March 3, 2025 – 2pm Eastern Time

2025 Mentorship Forum Application

Name:

First Name

Last Name

Credentials:

Title:

NPI#:

State and License number:

Current Position/Training Status:

PGY

Fellow

Other

Please specify the year of your position/training status (i.e. PGY-2, 1st Year Resident, or other)

If not Neurology, please indicate your specialization:

Applicant Address:

City, State/Province/ Zip

Country

Primary Phone:

Primary Email

Affiliation:

Affiliation Phone:

Affiliation Address:

City, State/Province/ Zip

Country

Emergency Contact Name:

Emergency Contact Phone Number:

Emergency Contact Email Address:

BREAK OUT SESSION:

Please click the dropdown list and select your top 3 preferences for a break out session.

1st Choice:

2nd Choice:

3rd Choice:

QUESTIONS FOR THE MENTORSHIP FORUM:

So that we can provide you with the best experience, please take a minute to provide us with up to 2 questions that you would like to be addressed at the Mentorship Forum. Your response is very critical to the planning of this meeting.

Question 1:

Question 2:

Additional information required with this application form:

CV
Brief letter outlining your plans to implement the knowledge gained through this training opportunity.
Letter of recommendation and support from program director/supervisor/mentor.

Director/Supervisor/Mentor Name:

Director/Supervisor/Mentor Email:

Applicant Signature:

Date:

Return completed application materials via email to Nancy Chazen at nancy.chazen@mscare.org.
Incomplete applications will not be reviewed.

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