Membership Application Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Do you work primarily in clinical genetics (>50% of your time)? *YesNoWhat is your discipline? *Nurse Practitioner (NP)Physician Assistant/Associate (PA)Registered NurseGenetic CounselorGeneticistOther (please specify) much ethnicity? you (Other Discipline)What is the highest degree you have completed? *Master’s DegreeDoctor of Philosophy (PhD)Clinical Doctorate Degree (e.g., DNP, DMS, DMSc, DPA, DScPAS)Other Doctorate (please specify)(Other Degree)What is your gender identity? *MaleFemaleTransgenderNon-binary/non-conformingPrefer not to respondWhat is your race and/or ethnicity? *African American/BlackAmerican Indian/Native AmericanAsian/Pacific IslanderCaucasian/WhiteHispanic/LatinxMulti-racialOther (please specify)Prefer not to respond(Other Race/Ethnicity)In which state do you predominantly practice? *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingHow many years have you worked as a Genetics Advanced Practice Provider? *1-56-1011-1516-2525+What types of patients do you see? (select all that apply) *General (birth defects/multiple congenital anomalies, connective tissue disorders, developmental delay, autism, intellectual disability, epilepsy/seizures, hearing loss, neural tube defects, neurodegenerative disorders, neurofibromatosis, overgrowth/hemihypertrophy, skeletal dysplasias, vascular malformations)Hereditary CancerLysosomal Storage DiseaseMetabolic (inborn errors of metabolism, mitochondrial, newborn screening follow-up)Research/Clinical TrialsOther (please specify)(Other Patients)Would you be willing to serve as a preceptor for APP students? *YesNoAre you interested in being mentored? *Yes (I have 0-2 years of experience in genetics)Yes (I have 2-5 years of experience in genetics)Yes (I have 5 or more years of experience in genetics)NoWould you prefer one-on-one mentorship or being part of a small cohort of mentees meeting with a single mentor? *I prefer one-on-one mentorshipI prefer to be a part of a small cohort meeting with a single mentorI have no preference between one on one or small cohort mentorshipHow much time would you like to devote to being mentored? *1 hour per month for 6-12 months2 hours per month for 6-12 months4 hours per month for 6-12 monthsAs neededAre you interested in being a mentor? *Yes (I have 0-2 years of experience in genetics)Yes (I have 2-5 years of experience in genetics)Yes (I have 5 or more years of experience in genetics)NoWould you prefer one-on-one mentorship or mentoring a small cohort of mentees? *I prefer one on one mentorshipI prefer to mentor a small cohort of menteesI have no preference between one on one or small cohort mentorshipHow much time would you like to devote to mentoring? *1 hour per month for 6-12 months2 hours per month for 6-12 months4 hours per month for 6-12 monthsAs needed onlyQuestions or CommentsSubmit
