2022-2024 Future Leaders Program Application

1. Candidate Information

First Name *This question is required.

Last Name *This question is required.

Degree(s) *This question is required.

Job Title

Institution *This question is required.

Address *This question is required.

Apt/Suite/Office

City *This question is required.

State *This question is required.

Zip *This question is required.

The address listed above is: *This question is required.

Phone Number *This question is required. This question requires a valid number format.

Email Address *This question is required. This question requires a valid email address.

2. In what type of setting do you practice? (ex. Academic, multi-specialty group) *This question is required.

3. What is your primary practice area? *This question is required.

5. How did you hear about the Future Leaders Program? *This question is required.

What year(s) did you submit an application?

7. Please tell us about any past volunteerism and how you envision contributing to physiatry and to the Academy. *This question is required.

8. Brief statement in support of your application:

What interests you about the Future Leaders Program?
*This question is required.

9. A strong level of commitment and participation is required for this program. The two-year curriculum includes these in-person sessions where travel is required:

Year One

Association Management training at Annual Assembly
Participation in the spring Board of Governors meeting

Year Two

Media and leadership training at Annual Assembly
Advocacy training in Washington, DC
Program completion celebration at the following Annual Assembly

Please attest to the following statements by checking each box:
*This question is required.

I understand that I will be required to attend all components of the online and in-person curriculum.
I understand that if I can no longer participate I will let AAPM&R know as soon as possible.

10. Optional supporting materials: We invite you to share a brief (two to three-minute) video testimonial to supplement your written application. Please know this is optional, and not required.

If you elect to create one, please copy this URL into a new browser to upload your video:

https://aapmrorg-my.sharepoint.com/:f:/g/personal/mstrubel_aapmr_org/ElAfEjumCTtEvx-g5Tt0PnQByuzjrocTDYlrjSnyy0WdTA?e=jN9SFe

Please contact mstrubel@aapmr.org if you encounter any issues with the upload.

11. Electronic Signature
*This question is required.

Name

Date This question requires a valid date format of MM/DD/YYYY.

calendar

12. Attach CV

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