ASRS Retina Practice Mentee Application

Thank you for your interest in the ASRS Retina Practice Mentorship Program! 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

First Name, Middle Initial, Last Name
Your current position
Email address you would like ASRS to use to contact you.
Number you would like ASRS to use to connect with you.
Official name of your practice.

How many years have you had your current position.
List any formal or informal training.

Previous Experience (list up to 3 previous positions)

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

Mentee Considerations

Areas of Interest


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: