Applicant Information

Your Full name

Your Date of Birth

Your email

Your phone

Current School or Institution

Current Grade/Year

City & State of Residence

Mentorship Interest

What mentorship option are you applying for?
Digital Mentorship – $250 (one-time)Core Mentorship – $950/monthPremium Mentorship – $2,500/monthNot sure yet — I’d like to discuss

Are you available for in-person shadowing?
YesNoMaybe / Depends on schedule

When would you like to start? (Month/Year)

Background & Interests

Why are you interested in this mentorship program? (Short paragraph — 4–6 sentences)

What area of medicine, dermatology, or aesthetics excites you most? (Short answer)

Have you had any prior clinical or shadowing experience? (Yes/No, with brief description if yes)

What are your career goals? (e.g. medical school, nursing, aesthetics, PA, business, unsure, etc.)

Parent/Guardian Info (if under 18)

Parent/Guardian Full Name

Parent/Guardian Email

Parent/Guardian Phone Number

Your Resume / CV

Agreement & Next Steps

*I understand this is a paid mentorship program, and I will be responsible for payment if selected.

*I understand that shadowing is for observation only and does not include clinical work.

*I will follow all clinical etiquette and maintain professionalism including attire, attitude, and conduct.

*I certify that all information provided is accurate.

*By Submitting this form, you are opting in to receive emails/texts and voice calls/mail from Elite MD.