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Please enter your contact information below.(Required.)

First Name

Last Name

Preferred E-mail Address

Contact Phone Number

Suffix(Required.)

MD

DO

FAAFP

Additional/Other (please include other preferred suffix i.e. MPH, MBA, etc.)

I am a:(Required.)

Family Physician

Family Medicine Resident

Medical Student

Name of Practice/Institution/Residency Program/Medical School(Required.)

Current professional position or practice circumstance (title, short description - not more than 50 words. Example: Full scope private practice in... or Associate Program Director at..)(Required.)

I am interested in the following:(Required.)

Board of Directors

VAFP Committee

Attending AAFP National Conference of Constituency Leaders

Attending AAFP Family Medicine Advocacy Summit

Attending the AAFP National Conference for Residents and Students

Being a VAFP State Legislative Key Contact

Other (please specify)

Please select a committee(s) of interest below.

Please indicate areas of skill, experience and/or interest in the first column and if you select an area in the first column, use columns 2-4 to indicate level of skill, experience, interest.

Why do you want to serve VAFP as a Board member and/or Committee member? (not more than 125 words)

Explain any unique skills, abilities, or perspectives you can bring to the organization. (not more than 125 words)

Please list any groups or organizations that you could serve as a liaison to on behalf of VAFP. (not more than 125 words)

Race/Ethnicity (optional):

Gender Identity (optional):

I identify as one or more of the following AAFP designated constituency groups. (optional)

If there is any additional information you wish to share, please do so here. (not more than 125 words)

Virginia Academy of Family Physicians Leadership Interest Form