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Virginia Academy of Family Physicians Leadership Interest Form

Thank you for your interest in serving the VAFP.   There are multiple avenues in which you can volunteer to be involved in your Academy.  Please complete the questions below and someone from the VAFP staff or leadership team will contact you.  Please also email a copy of your CV to mlwhite@vafp.org.

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* Please enter your contact information below.

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* Suffix

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* I am a:

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* Name of Practice/Institution/Residency Program/Medical School

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* Current professional position or practice circumstance (title, short description - not more than 50 words. Example: Full scope private practice in... or Associate Program Director at..)

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* I am interested in the following:

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* Please select a committee(s) of interest below.

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* Please indicate areas of skill, experience and/or interest in the first column and if you select an area in the first column, use columns 2-4 to indicate level of skill, experience, interest.

  I have a Skill, Experience, and/or Interest I have high expertise in this area/experience I have some expertise in this area/experience I have limited expertise in this area/experience but am interested in learning more
Continuing medical education
Finance, accounting
Governmental advocacy
Graduate medical education
Information technology
Management
Outreach to communities
Outreach to future family physicians
Outreach to other organizations
Private sector advocacy
Public relations
Wellness/Work Life Balance

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* Why do you want to serve VAFP as a Board member and/or Committee member? (not more than 125 words)

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* Explain any unique skills, abilities, or perspectives you can bring to the organization. (not more than 125 words)

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* Please list any groups or organizations that you could serve as a liaison to on behalf of VAFP. (not more than 125 words)

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* Race/Ethnicity (optional):

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* Gender Identity (optional):

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* I identify as one or more of the following AAFP designated constituency groups. (optional)

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* If there is any additional information you wish to share, please do so here. (not more than 125 words)

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