Application: Surgical Education Scholars (SES) Program

Applications for the Class of 2023 are being accepted now.

Name*

First Last Suffix

I've Been an APGO Member Since*

(If you intend to join APGO to participate in this class, please type “2021.”)

Institution*

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

My Direct Phone Number*

Email*

My Local (Home) Mentor Will Be*

Local home mentor will be a resource for scholars at their home institution. They should be well-versed in conducting surgical education or research projects and should be able to help scholars navigate institutional policies/procedures regarding such research. Home mentors should also be available to meet with scholars monthly for progress updates, preferably in person.

Home Mentor Phone Number*

Home Mentor Job Title*

Home Mentor Email*

Is Home Mentor an APGO Member?*

Applicant's Major Educational Responsibilities*

APGO Faculty Development Seminar 2019

Attended
Presented

APGO Faculty Development Seminar 2020

Attended
Presented

APGO Faculty Development Seminar 2021

Attended
Presented

CREOG & APGO Annual Meeting 2019

Attended
Presented

CREOG & APGO Annual Meeting 2020

Attended
Presented

CREOG & APGO Annual Meeting 2021

Attended/Will Attend
Presented/Will Present

APGO Clerkship Directors' School 101 & 201 Attended/ Will Attend

January 2019
January 2020
February 2021

APGO Clerkship Directors' School 301 Attended/ Will Attend

January 2019
January 2020
March 2021

I was referred to the APGO SES Program by

Upload Supporting Documents*

Max. file size: 50 MB.

Please submit one .pdf containing all application documents.