DEI Rise Up Mentorship Program

Diversity, Equity and Inclusion (DEI) Rise Up Mentorship Program

MENTOR APPLICATION

This ASDS Rise Up Mentorship Program is designed to support underrepresented minority (URM*) individuals in dermatology who are looking for guidance and to expand their support network by pairing one or more seasoned mentor(s) with a mentee for the purpose of sharing with the mentee their professional knowledge, skills and experiences.

*URM is defined as Black, African-American, Mexican-American, Native American (American Indian, Alaska Native, and Native Hawaiian), and mainland Puerto Rican populations.

For more information, contact Tamika Walton, ASDS Governance Manager, at twalton@asds.net.

Yes! I want to be part of the ASDS Rise Up Mentorship Program and commit to the expectations of the role as a Mentor:*

Sign me up as a Mentor.

View the expectations at https://www.asds.net/medical-professionals/members-resources/asds-diversity-equity-and-inclusion

Name*

First Name

Last Name

Work Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Home Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Personal Email Address*

Work Email Address

Cell Phone

I understand that by signing this application, I can commit the time and fulfill the expectations of the role.

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Date/Time

I am also interested in participating in the DEI Ambassador Program

Yes, send me more information to participate in the DEI Ambassador Program No

Visit https://www.asds.net/asds-diversity-equity-and-inclusion for Ambassador Program updates.