ACT 2021 Media Training Application
Fill out the questions below to register for our Media Training Session, taking place on September 8, 2021 from 7:00-9:00 PM.
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1.
Full Name and Designation (MD, DO, NP, etc.):
(Required.)
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2.
Email Address:
(Required.)
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3.
Type of Practice:
(Required.)
Private (solo or group)
FQHC
Employed/Foundation Model (non-Kaiser)
Kaiser
Academic Setting
Other (please specify):
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4.
What media experience do you have already?
(Required.)
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5.
What are you most concerned about when speaking to the media?
(Required.)
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6.
What is your topic(s) of interest? Why is this important to you?
(Required.)
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7.
How do you plan on using this training in your advocacy work?
(Required.)
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8.
AAPCA1 values diversity in our work and we know that historically the media has been driven by a narrow perspective. What aspects of diversity do you bring?
(Required.)
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9.
What language(s) do you speak?
(Required.)
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10.
We would like to ensure that participants will have opportunities to use the skills they learn at this media training. We plan to add all attendees to our chapter spokesperson list where you may be called upon to give comment to the media on behalf of the chapter, please indicate if you DO NOT wish to be added.
(Required.)
Yes, sign me up!
No, I am not interested in being on the spokespersons list.
Thank you for applying. We will contact you once we have selected the cohort.
