Mentor application form

1. Preferred First Name:

2. Last Name

3. Email:

4. Phone:

5. Member Number

6. Current professional Role

7. Gender

8. Pronouns

9. Age

10. Describe race/ethnicity

11. Where you reside in NC

12. Where you work in NC

13. Typical current practice

Other - If you chose other on anything, please describe here.

14. How knowledgable are you about the value of APTA?

15. How knowledgable are you about the value of APTA NC?

16. Area of PT interest writ large (type of practice)

17. Other more narrow clinical interests (such as blood flow restriction, dry needling, manual therapy, NDT, Joint Positioning Error, Central Sensitization/Nociplastic pain, etc)

18. Other professional interests

19. Interests outside of PT (ex: running, exercise, cooking, reading, dogs, etc.)

20. For a mentee-match, please rank/list which topics are most important to you this year: location proximity, PT interest, other clinic interest, other professional interest, other outside PT interests.

21. What else about you or your experiences would help us make an effective match with a mentee?

Application to be a Mentor