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Name:
Degree:
Telephone Number:
Institution:
Address:
Email:
Ethnic Group (optional):

Gender (optional)

Male
Female

Area of Major Interest

Basic Research
Translational Research
Clinical Research
Clinical Practice

Academic Rank

Graduate Student
Postdoctoral Fellow
Clinical Fellow
Assistant Professor
Associate Professor
Professor
Other (optional):

Areas of Interest for this Mentoring Program

Basic Science Areas (check those that apply)

Esophagus
Gastric
Small Intestine
Colon
GI Motility Mechanisms
GI Sensory Mechanisms
Immune Modulation of Motility
Enteric Nerves and Glial Cells in Health and Disease
Interstitial Cells of Cajal in Health and Disease
Smooth Muscle in Health and Disease
Extrinsic Neural Pathways: Afferents and Efferents
Signaling: Hormones, Neurotransmitters, Receptors, Channels, Secondary Messengers
Mucosa and Neural Immune Functions
Miscellaneous Basic Science (optional):

Clinical Areas (check those that apply)

Esophagus
Gastric
Small Intestine
Colon
Anorectal
GI Motility
GI Sensation
Immune Modulation of Motility
Obesity, Nutrition, Appetite, Satiety
Functional Gastrointestinal Disorders: Psychosocial and Psychotherapeutic
Function Gastrointestinal Disorders: Symptoms, Diagnosis, Epidemiology
Treatment of GI Motility Disorders and Functional GI Disorders
Pharmacogenomics
Psychological and Alternative Therapeutics
Brain Imaging
GI Motility and Functional GI Disorders in Children and Adolescents
Pharmacogenomics
Miscellaneous Clinical (optional):

Areas of Interest for Mentoring (check those that apply)

Career Advancement
Grantmanship
Enhancing Professional Visibility
Methodological Approaches
Networking with Other Scientists
Publishing
Research Focus
Teaching
Clinical Practice
Other:

Membership Affiliation (check those that apply)

AGA
APS
Neurosciences
Functional Brain Gut
Other

Match Preference (optional)

Female
Male
Ethnic Group
Request for Potential Mentor? Name: (optional)
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Briefly describe what you would like out of this program:
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