ASRS's Empowerment and Opportunity Mentorship Program: Mentor Application 2026 - The American Society of Retina Specialists

Address

E-mail address*

Be sure to use an e-mail address that you will have access to for all of 2026!

Phone

Are you applying for the Family or Traditional Track Mentorship Program?*

If selected as a Family track mentor, are you also interested in being a Traditional track mentor for another mentee?*

Which years and tracks have you participated in this program? Check all that apply*

Practice Name*

Practice Location*

Practice Type. You can select more than one if applicable.*

If in a private practice, is your practice private equity owned?*

Year in Practice*

Title (Professor, Director of, Managing Partner, etc.)*

What are your areas of expertise and thus would feel comfortable advising on this topic(s)?*

Pronouns you identify with*

Gender Identity*

Race/Ethnicity. You can select more than one if applicable.*

If you identify as Asian, what country is your ancestry?

What is your cultural identity?

While many relate to their own race/ethnicity/sexual orientation, you can expand upon this

Were you or your parents first generation immigrants (first in family to become a US citizen) to the US?*

Do you identify as LGBTQIA+?*

If so, how do you identify? You can select more than one, if applicable.

Please share any disabilities that you are comfortable in disclosing. (State “None” if this doesn’t apply)*

Parent(s)/Guardian(s) Highest Level of Education*

Do you have family members that are (was) in the field of medicine?*

If yes to above, what is their profession?

Did you qualify for and or receive need-based financial assistance to attend college and or medical school?*

If this does not apply, put “n

Did you grow up in a rural, urban or suburban area?*

Would you consider the area you grew up in medically underserved?*

What percentage of your current practice serves the medically underserved?*

In 100 words or less, please describe your diversity, equity and inclusion vision for the field of retina? (Open)*

(characters remaining: 900)

In 100 words or less, please describe why you are applying to be part of the family or traditional track mentorship program?*

(characters remaining: 900)

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