Mentor Application

For practicing dermatology physicians and residents interested in being part of the Skin of Color Society’s Mentorship Program, here is a short article for what you may encounter as a Mentor, and what can be expected from this experience. Please fill out the form below and someone will contact you, thank you!

Mentorship Program

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Submit your interest to become a SOCS Mentor for the 2023-2024 Mentorship Program Year

Mentor Information
Name*
First Last Credentials (e.g MD, MBBS, DO)
Title
Phone*
Fax
Email*
Current Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Institutional Affiliation
Member of Skin of Society:*
- Yes
- No
Membership or pending-membership of the Skin of Color Society is a requirement for eligibility. Please complete your SOCS membership application before proceeding with the Mentorship application. https://www.registration123.com/SOCS/MEMBERSHIP/
Please select*
- Practicing Dermatologist
- Dermatology Resident
Area(s) of Expertise*
Mentorship Information
Do you have any suggestions or recommendations for the SOCS Mentorship Program?
Additional Information
ADDITIONAL INFORMATION
Please include a copy of your curriculum vitae with this application.*
Electronic Signature of Mentor*
I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.
Date
Name
First Last

Mentor Application

Mentor Information

Mentorship Information

Additional Information

ADDITIONAL INFORMATION

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