ALOMA Mentorship Program Thank you for taking the time to complete this survey. All fields are required. Full Name: Practice Location (City and Zip Code): Specialty (Check One): Allergy & ImmunologyNephrologyPreventative MedicineAnesthesiologyNeurological SurgeryPsychiatryCardiologyNeurologyPulmonologyDermatologyNuclear MedicineRadiation OncologyEmergency MedicineObstetrics & GynecologyRadiology - DiagnosticEndocrinologyOphthalmologyRheumatologyFamily MedicineOrthopedic SurgerySleep MedicineGastroenterologyOtolaryngologySurgery – GeneralGeriatric MedicinePathologyThoracic SurgeryHematology/OncologyPediatricsUrologyInfectious DiseasePhysical Medicine & RehabilitationOther:Internal MedicinePlastic SurgeryMedical Genetics I am willing to accept (for shadowing): Pre-medical students1st Year Medical Students (OMS-I)2nd Year Medical Students (OMS-II)3rd Year Medical Students (OMS-III)4th Year Medical Students (OMS-IV) I prefer to be contacted: By the student wishing to shadowBy an ALOMA representative I prefer to be contacted by: EmailTelephoneOther: Please enter your contact information. Practice/Company Name: Contact Person (office manager etc.): Address: City / Town: State: Zip Code: Email: Please check which months (tentatively) you are available for shadowing: JanuaryMaySeptemberFebruaryJuneOctoberMarchJulyNovemberAprilAugustDecember Please select what days of the week you prefer (tentatively) to be shadowed: MondayTuesdayWednesdayThursdayFridaySaturdaySunday By submitting this form, you are giving us permission to contact you about mentorship opportunities with ALOMA.