2023-2024 Mentorship Program Application for Mentors Save my progress and resume later | Resume a previously saved form Resume Later In order to be able to resume this form later, please enter your email and choose a password. Your Email: A Password: Confirm Password: Please complete the following application for consideration to serve as a mentor in the 2023-2024 PeDRA Mentorship Program. PeDRA is seeking 50 mentors to support the following types of mentees: medical student groups of no more than 3 students per group residents/interns/transitional year traineesclinical fellowsearly-to-mid-career investigators In recognition of your time and effort as a mentor, you will receive a $500 stipend and dedicated support from PeDRA Staff. Please submit your application by 5PM PT, Thursday, September 14, 2023. If you have questions about the program or the application, please email PeDRA's Associate Director of Education, Jenn Dawson. Thank you for your continued support of growing the next generation of researchers. Contact Details First Name Last Name Credentials Email Institution Position/Title In what year did you or will you complete your training? (ex: 2004) Which category best describes you:Dermatology residentPediatrics residentClinical fellowLess than 2 years out of trainingBetween 2 and 7 years out of trainingBetween 7-11 years out of trainingMore than 11 years out of training Which training or career stage would you like to mentor? (Check all that apply.)Medical student group (no more than 3 mentees)Dermatology residentPediatrics residentClinical fellowEarly investigator less than 2 years out of trainingEarly investigator between 2 and 7 years out of trainingMid-career investigator between 7-11 years out of training Which research area(s) do you have knowledge in and could mentor others? (Check all that apply.)Basic ScienceClinical TrialsEpidemiologyIndustry sponsored researchQuality ImprovementTranslational ResearchOther Please specify: Please identify up to four (4) PeDRA Focused Study Groups in which you are most involved and/or interested. Acne & Hidradenitis Suppurativa Atopic Dermatitis & Psoriasis Birthmarks Connective Tissue & Autoinflammatory Disorders Down Syndrome (sub group of genetics) Drugs & Bugs Genetic Skin Disorders Hair Disorders Neonatal Skin Care Skin of Color & Pigmentary Disorders Skin Tumors & Reactions to Cancer Therapies (STARC) Cross-Cutting Please identify the skills for which you feel comfortable providing mentorship. (Select as many as desired.) 360 leadership Academic promotion Conducting basic science research Conduction translational research Developing a niche Grant writing Manuscript peer review Negotiation/conflict resolution Networking SMART goal setting Statistics Study design/execution Work/life balance Working with industry Working with patient advocacy Other Please specify: Do you plan to attend any of the following meetings in the coming year? Please check all that apply.PeDRA Annual Conference - November 9-11, 2023, Atlanta, GAAmerican Academy of Dermatology - March 8-12, 2024, San Diego, CASociety for Investigative Dermatology - May 15-18, 2024, Dallas, TXSociety for Pediatric Dermatology - July 11-14, 2024, Toronto, CanadaOther(s) Please specify: Were you a mentor in the 2022-2023 PeDRA Mentorship Program?YesNo Briefly tell us about yourself and why you are interested in mentoring. (250 words maximum.) Demographics PeDRA is committed to supporting equity, diversity, and inclusion across all facets of its organization, programs, committees, leadership, and research studies. All data collected is kept safely and only de-identified aggregate data may be shared for strategic purposes. Please specify your gender:FemaleMaleNon-binaryI do not wish to provide this information. With what race(s) do you self-identify? Please select all that apply. American Indian or Alaska Native Asian Black or African American Hispanic or Latinx Middle Eastern or Northern African Native Hawaiian or other Pacific Islander White I do not wish to provide this information. Other Please specify: Save my progress and resume later | Resume a previously saved form Contact Information Return to Mentorship program Overview
