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Please enter a first name

First Name *

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Last Name *

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e.g. john.doe@glueup.com

Email *

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DEMOGRAPHICS

Gender *:

Test Group

Please select your gender * Female Male Prefer not to answer Other

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City *

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State/Province * Alabama American Samoa Alaska Arizona Arkansas Armed Forces Africa Armed Forces Canada Armed Forces Europe Armed Forces Americas Armed Forces Middle East Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Kansas Kentucky Louisiana Guam Hawaii Marshall Islands Illinois Indiana Idaho Iowa Massachusetts Maine Michigan Maryland Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming

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State/Province * Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador North West Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

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Medical School *:

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Medical School * Dalhousie University McGill University McMaster University Memorial University of Newfoundland Northern Ontario School of Medicine Queen's University Université de Montréal Université de Sherbrooke Université Laval University of Alberta University of British Columbia University of Calgary University of Manitoba University of Ottawa University of Saskatchewan University of Toronto Western University

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Anticipated medical school graduation year * 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 Other

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Anticipated medical school graduation year *

2022 *

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2022 *

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2032 *

Other *

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Other *

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Anticipated medical school graduation year *

Medical school identification or proof of enrolment *:Click here to upload a file

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Do you self-identify as Black? *YesNo

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How do you identify? *:

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How do you identify? * African-Canadian African Afro-Caribbean African-Arab African-Indigenous Hispanic Mixed Race Other

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MENTORSHIP

Would you be interested in mentoring?Medical StudentsPre-medical StudentsHigh School Students

Would you be interested in being mentored? *YesNo

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LEADERSHIP & ADVOCACY

Do you have research experience/expertise? *YesNo

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EVENTS

Would you be interested in participating in wellness events hosted by BPC? *YesNo

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Would you be interested in financial literacy training hosted by BPC? *YesNo

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NETWORK & COMMUNITY BUILDING

Would you attend an in-person national conference held by BPC within the next three years (as permitted by COVID-19 restrictions and public health guidelines)? *YesNo

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SUGGESTIONS

Do you have any comments, questions, or initiatives you would like BPC to address?

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