2024-2026 AAPM&R 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.

Current 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.

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

3. The AAPM&R Future Leaders Program is generally best suited for early career physiatrists who have completed residency and fellowship training, and have been in practice 3-10. Where you are at with respect to this window?

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

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

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

8. Please tell us about any volunteerism experience you have. *This question is required.

9. While this program does not require any leadership training or experience in advance, please tell us about any leadership training you have received and/or any leadership experience you have.

10. Please explain what interests you about the AAPM&R Future Leaders Program? What do you hope to get out of it?
*This question is required.

11. Is there anything that you would like to share about yourself that has not been covered in a previous question?

12. 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 and Media training at Annual Assembly
Strategic Planning with the AAPM&R Board of Governors at their Spring 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 curriculum.
I understand that if I cannot participate I will let AAPM&R know as soon as possible.

13. Electronic Signature
*This question is required.

Name

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

calendar

14. Attach CV

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