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Minimum requirements to apply for an SRFC steering committee position are as follows:
1. Attend an interest meeting (or meet privately with one of the current committee members)
2. Make at least one clinic visit if you have not already volunteered

The application must be submitted by Tuesday, December 21st, 2012 by 5 PM. These applications will be reviewed and all applicants will be notified to schedule an interview on Monday, January 14th. Thank you for your time and interest. If you have any questions, please contact David Finkelstein at davidmf2@gmail.com

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Name and email:

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Please rank your preference of what position you would like to apply for (1 = high, 4 = low). Indicate if there is a specific position that you would not want to serve at all with an X. Please remember that only MD/PhD students may hold the CH Liaison position.

	High			Low	X
CH Liaison	*Please rank your preference of what position you would like to apply for (1 = high, 4 = low). Indicate if there is a specific position that you would not want to serve at all with an X. Please remember that only MD/PhD students may hold the CH Liaison position. CH Liaison High	CH Liaison	CH Liaison	CH Liaison Low	CH Liaison X
M1 Coordinator	M1 Coordinator High	M1 Coordinator	M1 Coordinator	M1 Coordinator Low	M1 Coordinator X
Interpreter Coordinator	Interpreter Coordinator High	Interpreter Coordinator	Interpreter Coordinator	Interpreter Coordinator Low	Interpreter Coordinator X
Health Education	Health Education High	Health Education	Health Education	Health Education Low	Health Education X
Fundraiser	Fundraiser High	Fundraiser	Fundraiser	Fundraiser Low	Fundraiser X

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Why do you want to serve on the steering committee and why are you interested in your top choice?

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What qualities would you bring to the steering committee and how would they benefit the committee?

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What other extracurricular commitments do you currently have? Please list and describe average time commitment in hours per week.

Is there anything else you would like to add?

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If you are not selected to be on the steering committee would you still be interested in volunteering?

If you are not selected to be on the steering committee would you still be interested in volunteering? Yes

No

Please note that all interviews for the Steering Committee will take place on Monday, January 14th. Please make travel arrangements accordingly.