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Expression of Interest

Please use this Expression of Interest form to indicate your interest in participating in the MICCAI Society Mentorship Program as a mentor or mentee.

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* 1. Name

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* 2. Position

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* 3. Affiliation

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* 5. In which role would you like to participate in the Mentorship Program?

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* 6. What is your highest degree?

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* 7. Please share any additional information or comments that you would like share to be considered. For any additional questions contact: mentorship@miccai.org

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* 8. Are you a MICCAI Society Member?

To become a member, visit www.miccai.org
Term and Conditions

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* 9. Please confirm that you have read the details regarding your expected duties and management process. (www.miccai.org/about-miccai/miccai-society-mentorship-program)

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* 10. Do you agree to have your name published on the MICCAI Society website or in other materials?

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