2025 EAST Executive Leadership Coaching and Mentoring Program Application

Thank you for your interest as an Evolving Leader in the 2025 EAST Executive Leadership Coaching and Mentoring Program.  The EAST Executive Leadership Coaching and Mentoring Program targets mid-career EAST members that have shown leadership qualities and commitment to the EAST Mission and Vision.

Evolving Leader Requirements:

1. You must be a current EAST member in good standing and membership dues paid in full.
2. You must have completed or plan to complete at least 1-year of the 3-year EAST Leadership Development Workshop series during the mentorship program if selected.
3. The EAST Leadership Development Workshop is held annually in conjunction with the EAST Annual Scientific Assembly. Or, you must be registered to attend an upcoming workshop at the next assembly.
4. Physicians must be mid-career (at least 5-years out of training and preparing to assume new responsibilities, an administrative role, or promotion).
5. Have served on at least one EAST committee.
6. Be willing and able to participate in the 2-year 2025 EAST Executive Leadership Coaching and Mentoring Program (July 2025-July 2027).
7. Complete the online application and upload your curriculum vitae (CV) for matching purposes.

The EAST Mentoring Committee will review and score all applications.  Six Evolving Leaders will be selected and matched to Executive Leaders by the end of July to participate in the 2025 EAST Executive Leadership Coaching and Mentoring Program.

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Evolving Leader Information

Full Name*

Include full name and degrees/credentials

Email Address*

Institutional and/or Military Affiliation*

Position*

EAST Membership Type/Category*

Active/Provisional/Associate

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EAST Accomplishments

I have completed at least 1-year of the 3-year EAST Leadership Development Workshop series.*

• Yes
• No
• I am planning to attend the 2026 or future workshops at the EAST Annual Scientific Assembly.

I have served on at least one EAST committee.*

• Yes
• No

Please provide any additional information on how you have been involved as a member of EAST.

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Personal Statements

Explain why you wish to participate in the program.*

Provide a brief description of your career trajectory thus far.*

Please list 3 objectives that you hope to achieve as a result of this program:*

3 separate objectives must be provided. SMART goals.

What long term goals do you have & how do you envision this program helping you achieve them? *

Roles (TMD, Division Chief), Research (grants/obtain lab), Global Health/Surgical Humanitarianism

Are there any additional leadership development programs you have attending? *

List them above if applicable.

What are the core values of your ideal Executive Leader (Mentor)? *

Please list EAST member(s) that you would be interested in having as your Executive Leader:*

It is not guaranteed if selected for the program this would be your assigned Executive Leader.

What drives you and what you are passionate about?*

Additional Information

List any additional information that you feel is relevant.

Upload your curriculum vitae (CV) for matching purposes.*

Accepted Formats: .pdf, .doc, .docx, .png, .jpg

If selected, are you comfortable w/us sharing your application with your selected Mentor?*

• Yes
• No

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