APTA Geriatrics Nomination Form - 2022

The Nominating Committee annually seeks recommendations for nominees. Complete this nomination form to confirm your interest and give your consent in being considered for running for office.

Nominations are due by midnight central time on Monday, June 6, 2022

About the Nominee

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* 1. Full Name and designations (as it appears in your APTA member profile):

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* 2. Select any designation that applies to you.

Board-Certified Geriatric Clinical Specialist

Certified Exercise Expert for Aging Adults

Advanced Certified Exercise Expert for Aging Adults

Credentialed Balance and Falls Professional

Other (please specify)

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* 3. Contact information

Company/Organization

Address

City

State

ZIP/Postal Code

Email Address

Phone Number

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* 4. APTA Geriatrics Membership ID #:

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* 5. Please rank the positions for which you would like to serve, and in order of preference (1 = most interested, 9 = least interested). Note that the Nominating Committee reserves the right to slate candidates for any position, regardless of their selection preferences (except for any positions of which they opt-out).

Board of Directors: Secretary

Board of Directors: Chief Delegate

Board of Directors: Director

Nominating Committee: Member

Bone Health SIG: Chair (2 year term)

Global Health for Aging Adults SIG: Chair (2 year term)

Residency and Fellowship SIG: Chair (2 year term)

Cognitive and Mental Health SIG: Vice Chair (3 year term)

Health Promotion and Wellness SIG: Vice Chair (3 year term)

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* 6. Please select any positions of which you prefer to opt-out from:

OPT-OUT for Board of Directors: Secretary

OPT-OUT for Board of Directors: Chief Delegate

OPT-OUT for Board of Directors: Director

OPT-OUT for Nominating Committee: Member

OPT-OUT for Bone Health SIG: Chair (2 year term)

OPT-OUT for Global Health for Aging Adults SIG: Chair (2 year term)

OPT-OUT for Residency and Fellowship SIG: Chair (2 year term)

OPT-OUT for Cognitive and Mental Health SIG: Vice Chair (3 year term)

OPT-OUT for Health Promotion and Wellness SIG: Vice Chair (3 year term)

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* 7. Please briefly describe for us what you believe to be your most significant accomplishments as a leader as it relates to advocacy for our profession. (150 words or less):

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* 8. Please describe the activities you've participated in to support APTA Geriatrics, APTA State Chapter and or the National APTA Organizations. Additionally, list any relevant not-for-profit leadership experience you may have.

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* 9. Is there any other information you would like the Nominating Committee to know about you as they determine the slate for this year?

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* 10. Summarize your answers to the questions above to create a brief bio to be published in the August issue of GeriNotes. (Tip: In 200 words or less, using first-person pronouns such as "I" or "me.")

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* 11. Please confirm:

I consent to serve, if elected, in any office (except for those of which I've opted-out) and conduct the duties of that office as described in APTA Geriatrics Bylaws and policies.

I understand that to be considered to be slated for an office, that I must be an active member of the APTA Geriatrics and maintain my membership through the entire term of my office if elected. Failure to renew my membership at any time during my term of office will result in immediate removal from office.

I verify that I meet the eligibility requirements to serve in office.

I understand that in the event I am slated to run for office, that my name, designations, and any information I have provided on this form may be shared with the APTA Geriatrics membership in promotion of the annual election.

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* 12. Please upload your curriculum vitae (CV) here:

PDF, DOC, DOCX file types only.

Choose File

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* 13. Please upload your headshot here:

PNG, JPG, JPEG, GIF file types only.

Choose File

Thank you! We will review the information you have provided, and if we have any questions, we'll contact you during the vetting process. You will be notified via email whether or not you have been slated for a position.

-The APTA Geriatrics Nominating Committee