Toggle navigation
scrubsandheels.com
scrubsandheels.com
Home
Mission
LEADERSHIP SUMMIT
Archive
Media
Podcasts
Archive
Applications Forms
AMBASSADOR APPLICATION
MATRIX MENTORSHIP
BREAK THE GLASS CEILING AWARD
Log In
Sign Up
Personal information
First Name
*
Date of Birth
*
Last Name
*
Gender
*
Male
Female
Other/Non-binary
Username
*
User Password
*
Confirm Password
*
How do you describe your Race and or ethnicity
*
How do you describe your Race and or ethnicity
White
Black or African-American
Asian
Middle-Eastern
Hispanic or Latino
Pacific Islander
American Indian
Other
Social Media Handles
Instagram
Linkedin
Facebook
Twitter
*
Number
APT Number
State / County
*
Phone / Mobile Number
Profile Picture
Remove
Take Picture
Upload file
Professional information
Street Name
Town / City
Postcode / Zip
User Email
*
Institution
*
If MD/DO, Career stage
*
Resident
Fellow
practicing clinician
Not Applicable
Practicing Gastroenterologist : years since fellowship
*
0-5 years
6-10 years
> 10 years
Not applicable
If Practicing clinician:
*
Private practice
Academia
Employee of a hospital system
Governmental organization
Other
Other practicing clinicians (APP, Pharma D, Psych, RD…) : years in practice
*
0-5 years
6-10 years
> 10 years
Not applicable
Degree
*
Gastroenterologist (MD/DO)
Non-GI MD/DO
Advanced Practitoner (NP,PA)
Registered Dietician
PharmD
Psychologist
Nurse
Other
Focus in GI : (check all that apply)
*
General Adult GI
Pediatric GI
IBD
Therapeutic endoscopy
Motility Disorders
Esophageal Disease
IBS
Liver disease
Pancreatobiliary disease
Obesity medicine
Basic Science and/or Translational research
Other
Get involved with the Scrubs & Heels Foundation !
1- if your are interested in joining a S & H Committee and / or Faculty ( Check all that applies)
*
Social media ambassador (open to residents and fellows only)
Summit ambassador (open to residents and fellows only)
Mentor for the Matrix Mentorship program (open to practicing gastroenterologists only)
Faculty at the Summit
Faculty for podcast
Writer for newsletter
Other
2- Do you give permission to Scrubs & Heels to (check all that applies)
*
email you our newsletter
share your info with colleagues for networking and professional opportunities
share your info with industry partners for networking and professional opportunities
Use pictures taken during summit or other S and H event to be shared on our social media and website
Submit
IMPORTANT NOTICE
APPLICATION FOR SCRUBS & HEELS AMBASSADORS
and
APPLICATION FOR THE BREAK THE GLASS CEILING AWARD NOW OPEN
APPLY BY AUGUST 15, 2024
CLOSE
Register for the event
CLOSE
welcome to this site
https://scrubsandheels.com/wp-admin/post.php?post=6248&action=edit
CLOSE
