*1.Please provide the following contact information:(Required.)

Name (first, last):

Institution/Practice:

Title: 

Email Address:

AAP ID#:

*2.Please list current/past roles in the AAP (local, district or national) and describe any current/past leadership activities outside of AAP.

How do you plan to balance your current commitments with this new responsibility?(Required.)

*3.Please describe your interest in becoming an Advocacy Committee Co-Chair including any specific contributions you would like to make to the Chapter and any specific topical interests (300 word limit).(Required.)

*4.Please describe experiences that you have with fostering diversity, equity and inclusion in a professional setting.(Required.)

*5.Narrative biosketch: Please provide a brief biography here(Required.)

6.Upload your CV here.

Please email CV to info@aapca1.org if you encounter any difficulty with uploading here.

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