In a few short minutes, you will be enrolled in an exciting and innovative one-year virtual mentorship program JUST for fellows only, hosted by Academic Life in Emergency Medicine. We're excited to bring together the rising stars and leaders of EM.
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Contact information

 
First name *

 
Last name *

 
Degree(s) such as MD, DO, or MPH *

 
Street Address *

 
City *

 
State

 
Postal Code

 
Country

 
What is your Twitter handle (if you have one)?

 
The email you entered is " {{answer_16184531}}"

Is this correct? *

     
 
Institution information

 
Name of institution *

 
What is your fellowship area (e.g. EMS, Toxicology, Ultrasound)? *

 
Fellowship Director Name *

 
About you

We'd love to know more about you to help tailor this year's Incubator experience.
 
Are you planning to attend the SAEM 2016 Annual Meeting in New Orleans, LA where our big launch mixer / networking event will be? *


 
Tells us about any projects that you are planning on starting this year. *

 
What are you most nervous about as you begin your fellowship? *

 
What other medical interests do you have outside of your own Fellowship? *

 
Tells us about one big idea you’ve been thinking about that could only be done by coordinating with every other Fellow in your subspecialty. *

 
CV *

 
Fellowship Letter of Acceptance *

 
We got your information! The membership dues are $200 for the entire year. *

 
Please enter your Credit or Debit Card number: *

 
The CVC number: *

(3 or 4 digit security number on the back of your card)
 
The name on your card: *

 
Your card's expiry month: *


 
Your card's expiry year: *


We can't wait to get started and see you at our Launch Event at SAEM 2016 in New Orleans. We'll be contacting you very soon to enroll you into our private Slack-based community.
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