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 session with potential mentees. Mentors and mentees will be matched based on the information gathered through the application process and virtual meeting, 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 April 30, 2023.  We hope that mutually meaningful mentorship relationships will be fostered through this program.  If you have any questions, please do not hesitate to contact

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

Accepted Formats: .pdf, .doc, .docx, .png, .jpg
Accepted Formats: .pdf, .doc, .docx, .png, .jpg

Thank you for your interest! Please direct any questions to Monica Horton, Director of Practice Management at