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FMAS Scholarship Application Form

Application Information

AAFP - Application for the 2024 Family Medicine Advocacy Summit
Student & Resident Scholarship

Thank you for your interest in applying for the 2024 Family Medicine Advocacy Summit Student & Resident Scholarship. Please complete the application items below and upload your most recent Curriculum Vitae (CV) as a .doc, .docx, or .pdf. Once you submit your application you will receive a confirmation email to the address you provided in the application.

1. 1. Contact Information

First Name:
Last Name:
Email address:
Best phone number to reach you:
Address:
City, State, Zip:

2. 2. Which of the following best describes you?

2a. You selected Other, please specify:

3. Medical School Information

Medical School Name:
Medical School - City:
Medical School - State (list country if not in USA):

3. Residency Program Information

Residency Program Name:
Residency Program - Director:

3. 4. Are you an American Academy of Family Physicians (AAFP) member?

Please enter an 'other' value for this selection.

4. 5. Are you active in health policy activities with your state chapter?

5a. What advocacy activities are you involved in?

5b. Why are in interested in these advocacy activities?

5. 6. What legislative issues do you believe most affect family physicians?

6. 7. What do you hope to gain by attending the Family Medicine Advocacy Summit?

7. 8. How did you learn about this scholarship opportunity?

8. 9. Please upload your most recent curriculum vitae (CV) in one of the following file formats (.doc, .docx, .pdf). *This question is required.

File: {{filename}} delete

9. 10. Please provide any additional information you would like us to consider.