NCAFP Resident / Student Leadership Interest Form

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Deadline to submit this interest form, your CV and letter of recommendation to Tracie is May 31, 2020, 11:59 pm EST.

Before submitting your interest, please be aware of the available leadership roles. Position descriptions can be found here: file:///C:/Users/Tracie/Downloads/Summary%20of%20Resident%20&%20Student%20Leaders%20Positions%20(1).pdf

Meeting dates for all positions have not been confirmed for Dec. 2020 - Dec. 2021; however the 2021 meeting frequency will be similar to the 2020 schedule. You can find that here: file:///C:/Users/Tracie/Downloads/2019-20%20Meeting%20Schedule%20for%20Resident%20&%20Student%20Leaders%20(2).pdf

Specific meeting date / time is typically available at least 4 months prior to meeting - in most cases more notice than that will be provided. For most positions (except Board of Directors) we only meet face-to-face two or three times per year, to the degree you can control it, we expect you to make every effort to attend your respective meeting. If you have questions about the expectations and level of commitment please contact Tracie via below email or phone #.

* Complete this form and email your CV (3 page max) to thazelett@ncafp.com by 11:59 pm EST, 5/31/20.
* Submit a Letter of Recommendation - Residents should obtain this from your Program Director or Assistant PD. Students should obtain one from their FM faculty advisor or another family medicine faculty member.

The LOR should be on program/med school letterhead and provided to Tracie via email. It should speak to the qualities that make you an effective leader, your interest & involvement in family medicine / leadership roles to date and a willingness to support your requests for time off to attend meetings. The NCAFP is aware they cannot guarantee approved time off but there should be a willingness to consider your requests for time away from clinic/rotations/classroom to fulfill your obligations.

Thank you for your interest, please direct questions to Tracie Hazelett, Mgr., Medical Student & Residency Relations at 919-980-5357 or via thazelett@ncafp.com

Email *

I am currently enrolled as a *

Medical Student

Family Medicine Resident

First, Middle I., Last Name and Credentials *

Mobile Phone# *

Name of Medical School or Residency Program in which you are currently enrolled. *

Anticipated Graduation Year *

2021 - We welcome your leadership, however it can be a challenge to fully serve once you enter residency - or a new job - even if you remain in state. Please give full consideration to your ability to fulfill the position's obligations.

2022

2023

Other:

Current City of Residence *

The position I wish to be considered as a Candidate for: *

Unless otherwise noted, all terms are for one year, December 2020 - December 2021.

NCAFP Director-Elect (one position for students, one for residents - 2-year term; 12/2020 - 12/2022)

NCAFP Foundation Trustee (two student & two resident trustees)

Representative: Member Satisfaction and Practice Environment Committee (one student & one resident)

Representative: Payer and System Advocacy Committee (one student & one resident)

Representative: Workforce Pipeline Committee (one student & one resident)

I am willing to consider alternative roles as indicated: *

Willing to serve in any available position

Not interested in any other position

NCAFP Director-Elect (one position for students, one for residents - 2-year term; 12/2020 - 12/2022)

NCAFP Foundation Trustee (two student & two resident trustees 1-year term; 12/2020 - 12/2021)

Representative: Member Satisfaction and Practice Environment Committee (one student & one resident - 1-year term; 12/2020 - 12/2021)

Representative: Payer and System Advocacy Committee (one student & one resident - 1-year term; 12/2020 - 12/2021)

Representative: Workforce Pipeline Committee (one student & one resident - 1-year term; 12/2020 - 12/2021

Required

Statement of Interest *

Please write your statement of interest that includes the position you are most interested in, why you would like to serve and why you think you would be effective in that role. Please address your statement/letter to the NCAFP Nominating Committee. If you prefer to submit it as a separate attachment please do so as Word document and email it when you submit your CV.

Please check to confirm : *

I am a member of the AAFP/NCAFP

I understand if appointed I am expected to attend the 2 - 4 meetings (depending on position) held annually. Meetings are usually held Thurs. - Sun and will involve time away from class and/or rotations.

I understand if appointed I am expected to attend my respective Resident/Student section meeting at the NCAFP annual mtg in Asheville.

(Students only) I understand if appointed I am expected to attend the joint FMIG meetings held twice yearly: December in Asheville and March in Durham at Family Medicine Day, to update other student leaders on issues as appropriate.

Required

Additional Documents *

By checking the boxes below you have, or agree to send the following items to: Tracie Hazelett at the NCAFP offices as indicated below. The LOR can come through you or directly from the author to me via email: thazelett@ncafp.com

Current CV - WORD Document please - Must be received by the deadline, 5/31, 11:59pm

Letter of Recommendation - must be on letterhead - residents: should be from Program Director or Assistant PD; students: should be from your advisor or FM Dept faculty member - Must be received by above deadline.

Required

Full Name as Signature: *

Typing your Full Name in the Space Below represents your signature and agreement with responses provided in this submission. Please contact Tracie If you have questions or additional comments you wish to provide regarding your candidacy.

Date *

YYYY

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

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