California State University, Fresno
California State University, Fresno
Health Careers Opportunity Program
HEALTH PROFESSIONAL MENTOR PROGRAM
APPLICATION
Name: Student ID:
Permanent Address:
Street City Zip
Mailing Address:
Street City Zip
Cell Phone: Home Phone:
Fresno State e-mail:
Other e-mail:
Major: Option:
Minor:
Class Standing: ___ Freshman (0-29 units) Gender: ___ Female
___ Sophomore (30-59 units) ___ Male
___ Junior (60-89 units)
___ Senior (90+ units)
___ Postbaccalaureate / Graduate
Please respond to the following questions on a separate sheet of paper:
• Why are you interested in pursuing a career in medicine?
• What experiences have helped you develop an interest in medicine?
• Why do you want to participate in the Health Professional Mentoring Program (HPMP)
• Please tell us how you hope to benefit from the program?
• What are your expectations of the HPMP program and how will you contribute to the program?
Please read the following:
• As an HPMP student you will be required to attend a one hour monthly mentoring session with your physician mentor during the academic year. You will also be instructed to keep a log of your meeting times and days which you will be submitting to the HCOP office.
• If selected you will also be expected to attend all scheduled meetings with your physician mentor and with the HCOP-HPMP coordinator. As a participant you are expected to be punctual and professional at all times.
• If selected to participate, you will be required to attend a roundtable session with the HCOP-HPMP coordinator once per semester.
If selected to participate would you be willing and able to comply with the above requirements? ___ YES ___ NO ___ NOT SURE
Explain:
I have read the above requirements and understand that I must commit to and fully participate in the Health Professional Mentor Program and all related events and activities.
Signature Date
................
................
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