Diversity Mentorship Application Form

Personal details

* Title Title is required

* First name First name is required

* Last name Last name is required

* Address 1 Address 1 is required

Address 2

* Suburb Suburb is required

* State State is required

* Postcode Post code is required

* Country Country is required

* Email Email is required

* Mobile phone Phone is required

Information

* Career Stage

* University / Hospital / Practice
Please list institutions attended

How do you describe your gender identity?

* Do you identify as

* How would you describe your MAIN identity in cultural / ethnic terms?
Select only one - your MAIN identity

What language do you speak at home other than English?
Please list.

* I have an interest in Surgery as a career in medicine:

* I have an interest in Orthopaedic Surgery as a career in medicine:

Please provide main reasons for seeking an AOA diversity mentor.

* Preferred Diversity Mentor - Choice 1

* Preferred Diversity Mentor - Choice 2

* Preferred Diversity Mentor - Choice 3

I confirm the above information is accurate and correct (AU$.00)
Item will show as $0.00 no actual charge will be made.

Privacy policy

By submitting this form I provide consent for the information provided to be shared with one or more of the mentors listed and administration for the purpose of contact to be made, and as outlined as part of the AOA Diversity Mentors Program. I understand my information may also be used to provide additional materials relevant to AOA Diversity Mentors Program, resources, or event invitations.

I agree

Payment details

* Name on credit card Required

* Credit card number Required

* Credit card expiry month Required

* Credit card expiry year Required

* CCV Required

Payment amount

$0.00

If you require assistance with this registration, please contact Michelle White on michelle.white@aoa.org.au