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 monica.horton@asrs.org.

Name: First Name, Middle Initial, Last Name

Title: Your current position

Email address: Email address you would like ASRS to use to contact you.

Phone number: Number you would like ASRS to use to connect with you.

Retina practice name: Official name of your practice.

Practice location

Number of physicians in your practice (MD,DOs)

Years in current role: How many years have you had your current position.

Education or certifications or relevant experience: List any formal or informal training.

Previous Experience (list up to 3 previous positions)

Most recent previous position: Position held before your current one and brief description

Previous position: Previous position and brief description

Previous position: Previous position and brief description.

Mentee Considerations

: I agree to 1-2 conversations per month with my mentor for 6-12 months in addition to work or reading assigned from my mentor.

: I agree to evaluate my experience at the end of the session.

: I agree to inform ASRS of any concerns or questions I have as they arise.

Areas of Interest

Choose areas of interest that you and your mentor will work on.


: Cancel

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.