Application for NCAFP 4 Week Summer 2025 Externship

Before proceeding, please be aware the information you provide is the only thing the selection committee has available to them. While we do not want this to be a cumbersome process, please be thoughtful in the information you provide and take the time to proof-read the information you submit.

Participation and Preceptor matching is directed by the content within this application. This form, including the autobiographical statement, and a current curriculum vitae (NO more than TWO pages) must be submitted by 11:59pm February 28th, 2025.

In order for your application to be considered, you must be a member of the American Academy of Family Physicians (AAFP), and therefore a member of our state chapter, the NC Academy of Family Physicians (NCAFP). If you are not, please join asap at: www.aafp.org/join

If you have questions before getting started or at any point during the application process please contact Perry Price: perry@ncafp.com
____________________________________

NOTE re: your autobiographical statement. Your autobiographical / interest statement can be a modified version of your medical school application statement. However, please do modify it; reviewers notice when you do not take the time to do so.

Helpful hint: I suggest you create your statement in a word document prior to beginning this application, then copy / paste in the designated area below. Typical length varies but most range between 700 - 1400 words (1-2 pages).

NOTE re: Curriculum Vitae. Your CV should be no longer than 2 pages and must be attached to this form and submitted via email to Perry (perry@ncapf.com) by the deadline of 11:59pm on February 28th. PDFs only, please save as “FirstName_LastNameCV”. Anything beyond 2 pages will not be provided to the committee for review.

____________________________________

Program Info: Four-Week Externship: Flexible dates based on you / your preceptor's schedule. Sometimes two-week externships are also available.

Question Title

* 1. First Name

Question Title

* 2. Middle Name/Initial

Question Title

* 3. Last Name

Question Title

* 4. Email Address

Question Title

* 5. Secondary Email Address
*DIFFERENT from the first one you provided. At least one of the emails you give must be a "permanent" email that is NOT AFFILIATED with your school, i.e. please provide a Gmail account.

Question Title

* 6. Mobile Number

Question Title

* 7. Date of Birth

Please use the calendar.

Date

Question Title

* 8. Sex:
Answers do not affect consideration given to your application. Information provided will be considered when making host home assignments.

Male

Female

Nonbinary

Question Title

* 9. Medical School

Brody

Campbell

Duke

UNC

Wake Forest

Question Title

* 10. Please note your last day of exams/classes for M1 year:

Please use the calendar.

Date

Question Title

* 11. Please note your first day of classes for M2 year:

Please use the calendar.

Date

Question Title

* 12. Current Mailing Address
Please use your personal, LOCAL address, not your parents or other address you might consider more permanent.

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Question Title

* 13. US Citizen?

Yes

Question Title

* 14. Legal resident of what state?

State/Province

Question Title

* 15. How long have you lived in NC?

Less than 1 year

1-5 years

6-10 years

10+ years

Question Title

* 16. Emergency Contact Name and Relationship

Question Title

* 17. Emergency Contact Information

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number

Question Title

* 18. Undergraduate Education:
Please indicate NAME, CITY and STATE of academic institution as well as DEGREE received. Ex: School / City / State / Degree

Question Title

* 19. Graduate Education:
Please indicate NAME, CITY and STATE of academic institution as well as DEGREE received. Ex: School / City / State / Degree

Question Title

* 20. Geographical Preference
Please list at least 2 towns/cities/regions where you would like to be placed for your externship. Housing is NOT provided during the 4 Week Externship, so please indicate areas where you have housing available. Think about where you will be living next summer and how far you are able to commute.

Choice 1

Choice 2

Choice 3

Question Title

* 21. Preceptor / Practice Preferences:
Please check if you have preferences. Note: attempts are made to accommodate requests but cannot be guaranteed.

No Preference

Male

Female

Minority

Group Practice

Solo Practice

Direct Primary Care

Rural

Urban

Other Underserved area

Other (please specify)

Question Title

* 22. Interest Areas:
Family Physicians see the spectrum from newborn to the elderly; however, if you have a particular area of interest please specify. Preferences are helpful but cannot be guaranteed.

Adolescents

Behavioral Health

Geriatrics

Gender Affirming Care

Healthcare Policy / Advocay

Hospice / Palliative Care

Inpatient

Obstetrics

Pediatrics

Sports Medicine

Substance Use Treatment / Opioids / Suboxone

Women's Health

Other (please specify)

Question Title

* 23. Do you have any preceptor preferences not referenced above?

Question Title

* 24. Timeline for Externship
The greater your flexibility the better the chances of matching a preceptor with your geographical and / or interest area(s). Note: The 4 weeks could be completed non-consecutively based on preceptor availability. Scheduling modifications can be made for Duke medical students due to shortened summer break. Please note ALL time periods currently available (I know it's subject to change - we'll have further communications as we work together once programs are confirmed).

Question Title

* 25. Do you speak any languages in addition to English?
Please indicate level of fluency; are you conversational or do you have basic/survival language skills?

Question Title

* 26. If needed, please explain any animal, dietary or environmental considerations:

Question Title

* 27. Other Summer Commitments?
Many students participate in NCAFP programs in addition to other summer activities. This is very do-able and we work with students as schedules become confirmed. However, if you already know of research, mission trips, personal travel commitments, etc. it is helpful to know up front. Please list them - and the dates if known - below. As dates become confirmed or other activities are arranged in the months following submission of this application, please send a message to Perry to keep her informed. This is not communicated to the selection committee and does not affect your chances of program offers. It is merely important, helpful information.

Question Title

* 28. Other Comments?
Please use this space if there is anything else you would like to further explain, clarify or offer for consideration within this application.

Question Title

* 29. Physician Reference Contact 1
Please provide the name, phone # and e-mail address of TWO physicians (at least one in the FM dept. at your medical school preferred). These should be faculty or physician mentors that know you as a person/student - they do not need to know your GPA, class rank, etc. These individuals will serve as more of a character reference in case NCAFP Staff have questions or need more information.

Name

Company

Email Address

Phone Number

Question Title

* 30. Physician Reference Contact 2
Please provide the name, phone # and e-mail address of TWO physicians (at least one in the FM dept. at your medical school preferred). These should be faculty or physician mentors that know you as a person/student - they do not need to know your GPA, class rank, etc. These individuals will serve as more of a character reference in case NCAFP Staff have questions or need more information.

Name

Company

Email Address

Phone Number

Question Title

* 31. Participation Acknowledgement And Release and Waiver From Liability

All selected participants will be expected to sign a waiver form once program offers are extended. However, at this time please review the below, by checking the boxes and electronically signing (further below) you are indicating your understanding of the following:

I understand that that I may be asked to participate in a scheduled phone call with Perry at the NCAFP offices prior to confirmed participation in any program.

The NCAFP Foundation will consider my preferences for preceptor matches but cannot guarantee specific requests.

I understand the purpose of the stipend I receive is to assist with housing and travel related costs incurred as a result of placement in a community-based practice.

I understand that although assistance will be provided by the NCAFP, I am responsible for housing arrangements and expenses during my externship.

I understand that I must notify the Foundation as soon as possible of any changes in my availability; or, if once started a change in the duration of my summer experience.

If selected to participate I will be required to submit immunization records, including COVID vaccination, a valid TB test (cannot be older than 1 year at the time the clinical experience is expected to take place), and proof of Blood Borne Pathogen, Tuberculosis, OSHA and HIPAA training.

In addition to the above I may be required to submit other records, complete other forms and/or complete said training above specific to the clinic I am assigned.

I understand this summer experience does not qualify as part of my medical school's required core curriculum; as such I am NOT covered under my school's liability insurance protection. Therefore practices may not allow activities other than "shadowing". Examples of the experience could include patient interviews, history taking, basic physical exams, clinical discussions to encourage critical thinking and shadowing and observation.

By signing, I______(read your name)__________ for myself, my heirs and my personal representatives, do hereby release and forever discharge the North Carolina Academy of Family Physicians (NCAFP), all of it's officers, agents and employees from any and all claims for damages beyond the control of and without the fault or negligence of NCAFP, it's officers, agents or employees which are suffered by me as a result of my participation in these activities. I specifically assume all risks which may result from my volunteer and shadowing activities including any exposure to potential infections to which I may be exposed. The risks being known and appreciated by me having read this release and knowing these facts and in consideration of being allowed to participate.

I acknowledge that NCAFP's decision to allow me to participate is a privilege. I understand that this privilege may be rescinded by the NCAFP at their discretion. I also fully understand that my participation in shadowing activities is voluntary and I am not required to participate.

I also agree to abide by applicable clinic (specific to your assignment) policies and assume for myself full and complete responsibilities for any intentional infractions thereof and for any or all consequences of such infractions. I specifically understand that during my participation in volunteer / shadowing activities, I am prohibited from treating patients and I accept responsibility for any consequences of violation of this prohibition. I also accept full responsibility for any uses of the clinic facilities and agree to make full restitution with regards to any compensation required as a result of my use, misuse or damage to such properties.

I certify that I am covered by health insurance and that I will provide a copy of the certificate of insurance if selected to participate in an NCAFP program.

Question Title

* 32. Autobiographical Information / Interest Statement
Typical length varies but most range between 700 - 1400 words (1-2 pages). Remember, this is the primary source of information available to the selection committee. This information will be utilized by them and also shared with your Preceptor should you choose/be selected to participate. Information to consider includes:
• Personal information you feel is pertinent to your education and career choices, specifically how they relate to family medicine/primary care
• Influences to enter medical school
• Community service and/or involvement
• Leadership positions you have held /opportunities to lead
• Future professional and personal goals
• Describe experiences you have had in health care or research that have impacted you
• Interests outside of medicine
• Characteristics you possess that you think will make you a great physician
• Your expectations regarding participation in one of these programs.

Question Title

* 33. CV Upload
Please save and submit PDF as "FirstName_LastNameCV"

Please save and submit PDF as "FirstName_LastNameCV"

PDF file types only.

Choose File

Application for NCAFP 4 Week Summer 2025 Externship

Question Title

* 1. First Name

Question Title

* 2. Middle Name/Initial

Question Title

* 3. Last Name

Question Title

* 4. Email Address

Question Title

* 5. Secondary Email Address*DIFFERENT from the first one you provided. At least one of the emails you give must be a "permanent" email that is NOT AFFILIATED with your school, i.e. please provide a Gmail account.

Question Title

* 6. Mobile Number

Question Title

* 7. Date of Birth

Question Title

* 8. Sex:Answers do not affect consideration given to your application. Information provided will be considered when making host home assignments.

Question Title

* 9. Medical School

Question Title

* 10. Please note your last day of exams/classes for M1 year:

Question Title

* 11. Please note your first day of classes for M2 year:

Question Title

* 12. Current Mailing AddressPlease use your personal, LOCAL address, not your parents or other address you might consider more permanent.

Question Title

* 13. US Citizen?

Question Title

* 14. Legal resident of what state?

Question Title

* 15. How long have you lived in NC?

Question Title

* 16. Emergency Contact Name and Relationship

Question Title

* 17. Emergency Contact Information

Question Title

* 18. Undergraduate Education:Please indicate NAME, CITY and STATE of academic institution as well as DEGREE received. Ex: School / City / State / Degree

Question Title

* 19. Graduate Education: Please indicate NAME, CITY and STATE of academic institution as well as DEGREE received. Ex: School / City / State / Degree

Question Title

Question Title

* 21. Preceptor / Practice Preferences:Please check if you have preferences. Note: attempts are made to accommodate requests but cannot be guaranteed.

Question Title

* 22. Interest Areas:Family Physicians see the spectrum from newborn to the elderly; however, if you have a particular area of interest please specify. Preferences are helpful but cannot be guaranteed.

Question Title

* 23. Do you have any preceptor preferences not referenced above?

Question Title

Question Title

* 25. Do you speak any languages in addition to English?Please indicate level of fluency; are you conversational or do you have basic/survival language skills?

Question Title

* 26. If needed, please explain any animal, dietary or environmental considerations:

Question Title

Question Title

* 28. Other Comments?Please use this space if there is anything else you would like to further explain, clarify or offer for consideration within this application.

Question Title

Question Title

Question Title

Question Title

Question Title

* 33. CV UploadPlease save and submit PDF as "FirstName_LastNameCV"

Question Title

* 34. Your typed full name serves as your signature:

* 5. Secondary Email Address
*DIFFERENT from the first one you provided. At least one of the emails you give must be a "permanent" email that is NOT AFFILIATED with your school, i.e. please provide a Gmail account.

* 8. Sex:
Answers do not affect consideration given to your application. Information provided will be considered when making host home assignments.

* 12. Current Mailing Address
Please use your personal, LOCAL address, not your parents or other address you might consider more permanent.

* 18. Undergraduate Education:
Please indicate NAME, CITY and STATE of academic institution as well as DEGREE received. Ex: School / City / State / Degree

* 19. Graduate Education:
Please indicate NAME, CITY and STATE of academic institution as well as DEGREE received. Ex: School / City / State / Degree

* 21. Preceptor / Practice Preferences:
Please check if you have preferences. Note: attempts are made to accommodate requests but cannot be guaranteed.

* 22. Interest Areas:
Family Physicians see the spectrum from newborn to the elderly; however, if you have a particular area of interest please specify. Preferences are helpful but cannot be guaranteed.

* 25. Do you speak any languages in addition to English?
Please indicate level of fluency; are you conversational or do you have basic/survival language skills?

* 28. Other Comments?
Please use this space if there is anything else you would like to further explain, clarify or offer for consideration within this application.

* 33. CV Upload
Please save and submit PDF as "FirstName_LastNameCV"