Consent for storing submitted data

Yes, I give permission to store and process my data

Prefix (Dr, Prof, Mr, Ms, Mrs, Mx, Other)

First Name

Family Name

City

Country

Phone Number

Date of Birth

Are you a member of a National Chapter?

Yes

Current Job Title

Institution / Organization

Area of expertise in HPB Surgery

Years of experience

Please upload your CV/resume or a short outline of your qualifications and work experience

Are you willing to host fellows at your insitution

Yes

Specific support areas you can provide (please select all that apply)

Clinical Guidance

Research Mentorship

Career Development

Other

Availability for mentorship (e.g. number of hours per month)

Describe any previous experience mentoring trainees of fellows

Have you had any formal mentorship training

Yes

I agree to my contact details being included on the Kenneth Warren Fellowship mentor list on the IHPBA website

Yes

I agree to the IHPBA management office contacting me by email if required

Yes

Make a donation to the IHPBA, AHPBA, A‑PHPBA or E‑AHPBA Foundations.

Mentor Form