Lifestyle Medicine Interest Group Application

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Please complete this form to be considered for recognition as a Lifestyle Medicine Interest Group (LMIG) under the Philippine College of Lifestyle Medicine (PCLM)

Email *

Full Name *

Name of Academic Institution

Type of professional program/campus *

If you selected "Other" please briefly explain *

Institution address *

Is this a new or previously established LMIG? *

Option 1

LMIG leader name *

LMIG email address *

LMIG Advisor name *

Were you referred by another LMIG leader/advisor to establish a group at your institution? *

Yes

In your opinion what makes your institution a good location to establish a PCLM recognized LMIG? *

What resources or materials would like to develop for your LMIG? *

If approved, would you like grant funding to serve plant-based food at your next LMIG event? *

Target date of your LMIG inauguration *

YYYY

Terms and Agreement:

In order for a Lifestyle Medicine Interest Group (LMIG) to be recognized by the Philippine College of Lifestyle Medicine (PCLM), the organization is required to comply with the following conditions: 1) Act in the spirit of evidence-based lifestyle medicine, as defined by the Lifestyle Medicine standards 2) Host at least one student or faculty-oriented events per semester and one community-outreach event per year. Communicate updates with the ACLM membership committee including contact information and new officer elections 3) Submit annual reports by December 26th 4) Connect with a faculty advisor who shares the advocacy of lifestyle medicine and membership with the PCLM. Any organization who fails to operate within this conditions will be at risk of losing PCLM recognition and promotion as an official LMIG.

By checking the box, I agree and consent to the above PCLM LMIG Terms of Agreement.

Agree

A copy of your responses will be emailed to the address you provided.

Submit

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