2023 Poster Application Form

PHYSICIAN, RESIDENT AND STUDENT MEMBER SCHOLARLY ACTIVITY POSTER PRESENTATION

ELIGIBILITY

Clinical or educational research/case/scholarly activity that is relevant to family medicine that has been conducted in cooperation with a family medicine residency, a Florida medical student, or an FAFP active physician member. Membership in the AAFP/FAFP is a prerequisite for everyone listed on the submission.

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* 1. Submitter Status

Student

Resident

Physician

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* 2. Primary Author Status

Student

Resident

Practicing Physician/Faculty

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* 3. TITLE OF RESEARCH/CASE/SCHOLARLY PROJECT

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* 4. CATEGORY:

Quality Improvement

Research

Case Report

Research in Progress

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* 5. PRIMARY AUTHOR'S NAME AND PROFESSIONAL DESIGNATION

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* 6. SUBMISSION FOR:

Poster Presentation

Podium Presentation

Either if selected

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* 7. INSTITUTION/AFFILIATION

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* 8. MAILING ADDRESS

Name

Address

Address 2

City

State

Country

Phone Number

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* 9. CO-AUTHOR'S NAME (IF APPLICABLE) AND PROFESSIONAL DESIGNATION

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* 10. CO-AUTHOR'S STATUS

Student

Resident

Practicing Physician/Faculty

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* 11. CO-AUTHOR'S INSTITUTION/AFFILIATION

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* 12. CO-AUTHOR'S MAILING ADDRESS

Name

Address

Address 2

City

State

Country

Phone Number

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* 13. ADDITIONAL POSTER PRESENTERS AND PROFESSIONAL DESIGNATION List names and professional designation (as they should appear in the official program) of all others who contributed to the content of the exhibit.

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* 14. NAME OF POSTER (as you would like it to appear on the identification sign and in the official printed program)

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* 15. FINANCIAL SUPPORT (if any) PROVIDED BY:

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* 16. A TYPED, WRITTEN ABSTRACT OF YOUR PROJECT MUST ACCOMPANY THE APPLICATION FORM. PLEASE UPLOAD YOUR ABSTRACT HERE.

PDF, DOC, DOCX file types only.

Choose File

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* 17. AUTHORIZING SIGNATURE

By submission of this application for my poster, I am verifying that I have read and understand the conditions of the application as well as the terms as outlined in the application packet and I agree to abide by these terms. I further understand application and booth assignment will be determined by the FAFP.

This application/agreement is made and entered into by and between the FAFP and the entity and names in the application/contract printed in this brochure on the date set forth. The FAFP reserves the right to restrict any poster that, in the opinion of the FAFP, is deemed promotional, commercial, or unethical. The undersigned agrees that this application is effective and an agreement only on its acceptance by the FAFP. Please type your name below:

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* 18. PLEASE ENTER THE DATE

Date:

Date