User account

Username: *

Spaces are allowed; punctuation is not allowed except for periods, hyphens, and underscores.

E-mail address: *

A valid e-mail address. All e-mails from the system will be sent to this address. The e-mail address is not made public and will only be used if you wish to receive a new password or wish to receive certain news or notifications by e-mail.

Personal Details

First Name: *

Last Name: *

Gender: *

Female

Male

Employer: *

Division or Department:

Position:

Profession:

(e.g. engineer, biologist, etc...)

Area of Work or Research Focus:

Number of Years of Professional Experience:

CIHR Synapse Youth Mentor:

I am working on CIHR funded research

Contact Information

Primary Email Address: *

Alternate Email Address:

Work Phone Number: *

Home Phone Number:

Street Address:

Address (cont):

City: *

Province or Territory: *

Postal Code:

Mentorship Information

Please describe any previous experience you have presenting to youth or mentoring youth:

especially any work you have done with Actua or an Actua member:

Please share your ideas about how you would inspire a youth audience:

Please indicate as appropriate:

I am Aboriginal.

My work involves research in the area of Aboriginal health.

This information will help us place Aboriginal mentors and mentors with Aboriginal experience as role models in our programs delivered in Aboriginal communities.

What is your current availabilty for mentor events:

Please check all that apply. Note: Summer programs usually run from 9am to 4pm, Monday to Friday. During the school year select programs are offered on weekends or evenings.

Mentoring Locations

Please note Mentors are responsible for covering their own travel costs unless otherwise arranged.

Please select the Actua Member location that you would be most able to visit: *

Please list any other communities or regions that you could easily visit:		Order