LEAP Mentor Pool Applications 2017-2022

Thank you for submitting a nomination for the APA Minority Fellowship Program's LEAP Mentor Pool. Please complete the information below and upload the applicable documents. By completing this information, you are submitting your application for review. If approved, you will be added to the MFP website (editorial edits are possible) for available LEAP mentors and LEAP applicants will have the option to select you as a mentor. If they are selected as LEAP fellows, you will then have the opportunity to accept or decline the mentoring match. For more information, please visit: http://www.apa.org/pi/mfp. If you have any questions, please contact us at mfp@apa.org or (202) 336-6127.

First Name: *This question is required.

Last Name: *This question is required.

Degree: *This question is required.

Contact Information: *This question is required.

Address 1:
Address 2:
Address 3:
City:
State:
Zip:
Phone:
Email:

Institution: *This question is required.

Position: *This question is required.

Gender:

Please enter an 'other' value for this selection.

Ethnicity and Race Based on self-identification, select all boxes that apply to your ethnicity/race. Please provide additional information for each selected box (e.g. Cherokee, Haitian, Colombian).

Asian or Asian American (please specify) Please enter an 'other' value for this selection.
Black or African American(please specify) Please enter an 'other' value for this selection.
Hispanic or Latino(please specify) Please enter an 'other' value for this selection.
Native American / Alaska Native (please specify) Please enter an 'other' value for this selection.
Native Hawaiian or Other Pacific Islander
White or Caucasian (please specify) Please enter an 'other' value for this selection.
Other - Write In Please enter an 'other' value for this selection.

Have you been a fellow in any of the Minority Fellowship Programs (Psychology, Nursing, Psychiatric etc)?

Please list your relevant research areas with a few brief keywords:

Letter of Interest: *This question is required.

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Curriculum Vitae: *This question is required.

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Please paste a short professional biographical paragraph here (if you become a mentor, this will be used on the MFP/LEAP website):

Please upload a professional photo (if you become a mentor, this will be used on the MFP/LEAP website):

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LEAP Mentor Pool Applications 2017-2022

Mentors