Application for Summer 2024 NCAFP 2 Week Health Immersion Programs

Boone, NC - June 3rd - 14th, 2024
Concord, NC - July 15th - 26th, 2024

This application serves as application for both programs - you will have the chance to indicate your preference.

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 January 19th, 2024.

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 or 919-980-5357.

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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 January 19th. PDFs only, please save as “LastNameCV”. Anything beyond 2 pages will not be provided to the committee for review.

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Program Info: Each programs begins on Monday morning of the first week and ends the second Friday at close of clinic. You should plan to remain the entire 2 weeks, housing is provided continuously. That said, you do have free time Sat. a.m., thru Sun. evening if you need/want to leave for a previous commitment (wedding, family commitments, etc.). Communicate this to Perry and housing will be adjusted accordingly.

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* 1. First Name

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* 2. Middle Name/Initial

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* 3. Last Name

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* 4. Email Address

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* 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.

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* 6. Mobile Number

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* 7. Date of Birth

Please use the calendar.

Date

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

Male

Female

Nonbinary

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* 9. Medical School

Brody

Campbell

Duke

UNC

Wake Forest

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

Please use the calendar.

Date

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

Please use the calendar.

Date

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* 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

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* 13. US Citizen?

Yes

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* 14. Legal resident of what state?

State/Province

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* 15. How long have you lived in NC?

Less than 1 year

1-5 years

6-10 years

10+ years

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* 16. Emergency Contact Name and Relationship

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* 17. Emergency Contact Information

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number

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

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

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* 20. Please rank your program preference. If you are not interested or unable to participate in one of the options, please select N/A.

Western Immersion with MAHEC Boone Family Medicine Residency Program in Boone, NC

N/A

Rural/Suburban Immersion with Atrium Cabarrus Family Medicine Residency in Concord, NC

N/A

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* 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)

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* 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)

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

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* 24. 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?

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* 25. Allergies or Special Considerations?
For the purpose of host home assignments please note the following:

Cat allergies or fears

Dog allergies or fears

Other small animal allergies or fears (reptiles/hamsters/chickens/etc.)

Gluten Free diet

Vegetarian

Vegan

No special considerations

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

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* 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.

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* 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.

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* 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

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* 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

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* 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. Arrangements are made to stay with local FM residents or physicians however there will still be some food costs and commuting expenses.

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.

I understand these programs are scheduled for June 3-14, 2024 (Boone) and July 15-26, 2024 (Concord). The first week will be held at MAHEC Boone Family Medicine Residency in Boone, NC and Atrium Cabarrus Family Medicine Residency Program in Concord, NC respectively, with the second week to take place in a rural and/or underserved area in the surrounding area.

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.

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* 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.

Application for Summer 2024 NCAFP 2 Week Health Immersion Programs

Boone, NC - June 3rd - 14th, 2024Concord, NC - July 15th - 26th, 2024

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* 1. First Name

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* 2. Middle Name/Initial

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* 3. Last Name

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* 4. Email Address

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* 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.

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* 6. Mobile Number

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* 7. Date of Birth

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

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* 9. Medical School

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

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

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

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* 13. US Citizen?

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* 14. Legal resident of what state?

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* 15. How long have you lived in NC?

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* 16. Emergency Contact Name and Relationship

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* 17. Emergency Contact Information

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

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

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* 20. Please rank your program preference. If you are not interested or unable to participate in one of the options, please select N/A.

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

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* 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.

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

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* 24. 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?

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* 25. Allergies or Special Considerations?For the purpose of host home assignments please note the following:

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

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* 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.

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

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

Boone, NC - June 3rd - 14th, 2024
Concord, NC - July 15th - 26th, 2024

* 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.

* 24. 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?

* 25. Allergies or Special Considerations?
For the purpose of host home assignments please note the following:

* 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 "LastNameCV"