Washington Academy of Family Physicians
Pre-Med Student Mentorship Program
2006-2007
Application
(Please Print)
Name____________________________________________________________Male___ Female___
Address____________________________________City_________________State____ Zip_______
Telephone____________________________ E-mail________________________________________
College/University_________________________________ Location___________________________
Are you considering a career in Family Medicine? _______ Other Specialty________________________
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Summary of studies, interests and career goals:
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
I would like my mentor to be in the following geographical area (list all choices near hometown/campus):
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
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Upon completion of my mentorship experience, I agree to submit an evaluation summary to WAFP. My
comments may be included in a future WFP (Washington Family Physician) Journal.
Signature:____________________________________________________
Fax or e-mail Application to:
Beth Morris, Program & Committee Coordinator
425.486.0169
beth@wafp.net