ASRS Retina Practice Mentor Application

Thank you for your interest in the ASRS Retina Practice Mentorship Program! Selected mentors will be asked to attend a virtual mentor training session. Mentors and mentees will be matched based on the information gathered through the application process, and will be expected to communicate at regular intervals. In order to participate, you must be an active Retina Practice Administrator Section member, and be willing to affirm your commitment.  If you are interested, please fill out application no later than January 14, 2022.  We hope that mutually meaningful mentorship relationships will be fostered through this program.  If you have any questions, please do not hesitate to contact monica.horton@asrs.org.

First Name, Middle Initial, Last Name
Number you would like ASRS to use to connect with you.
Email address you would like ASRS to use to contact you.
Your current position
What is the official name of workplace

How many years have you had your current position.
List your degrees or certifications or experience that qualifies you for your current experience.

Previous Experience (list up to 3 previous positions)

Position held before your current one.
Previous position and brief description.
Previous position and brief description.

Mentor Responsibilities


Mentor Knowledge Base


Mentee Considerations

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Thank you for your interest! In addition to this form, please submit a resume and professional biography (not to exceed 1 page) to Monica Horton, Director of Practice Management at: monica.horton@asrs.org.