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IAMSE Medical Educator M-REACH Certificate Application
Please complete this form by April 15, 2023. If you have any questions or difficulities submitting the form, please email
support@iamse.org
for assistance.
The cost for the year-long M-REACH program is $500 for members and $700 for non-members. You will receive an invoice upon approval for the program.
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* Indicates required question
First and Last Name:
*
Your answer
Email Address:
*
Your answer
Institution (name and country)
*
Example: Harvard University, USA
Your answer
Preferred Address:
Your answer
Preferred Phone Number:
*
Your answer
What is your current academic title?
*
Professor
Associate Professor
Assistant Professor
Other:
If applicable, please list your administrative title:
Your answer
Are you currently an IAMSE member?
*
Yes
No
Unsure
Are you planning to attend the 2023 Annual IAMSE Conference in Cancun, Mexico?
*
Yes
No
Unsure
By participating in the IAMSE professional development M-REACH certificate program, what do you hope to achieve?
*
Please list 1-2 goals.
Your answer
Briefly describe past mentoring experience either within IAMSE or in a past/current role:
*
Your answer
Please indicate your availability to present at the 2024 annual conference:
*
The program, as planned, will include a project related to mentoring that will foster your ability to apply program content to practice.
Will definitely be there.
Unsure if I'll be able to attend at this time.
Definitely will not be there.
Describe your capacity to complete a project with a mentoring focus while in the program:
*
Do you have ideas for a project focused on mentoring either as a mentee or mentor? If yes, please describe.
Your answer
I have reviewed the
program description
and can commit to virtual didactic sessions that are planned:
*
If the above link doesn't work, copy and paste the following URL into your browser: http://www.iamse.org/wp-content/uploads/2023/02/Mentoring-Description-02.2023.pdf
Yes
No
Describe how your home institution will support (time, finances, etc.) your participation in the program:
Your answer
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