We've detected that Javascript is not enabled. It is required for an optimal survey taking experience.
Please check your browser's settings and make sure Javascript is turned on. Learn how to enable Javascript.

Skip survey header

2025 AAPM&R Resident Retreat Application

Please complete the following application to be considered for AAPM&R's resident retreat taking place May 17 - 18, 2025 and May 31 - June 1, 2025. The deadline to complete this application is January 15th, 2025.

1. First Name: *This question is required.

2. Last Name: *This question is required.

3. Degree(s): *This question is required.

4. Institution: *This question is required.

5. Address (Street, City, State, Zip): *This question is required.

6. Phone: *This question is required.

7. Preferred Email: *This question is required.

8. Is the above address your preferred mailing address? *This question is required.

9. Are you currently in your second year of PM&R residency? *This question is required.

10. Which course(s) are you applying to attend? (Note: We may not be able to accommodate changes at a later time) (Check one): *This question is required.

11. What clinical areas are you currently considering for your future career in PM&R Practice? (Note: It’s okay if you don’t know)! *This question is required.

12. Why do you want to participate in this program? *This question is required.

13. Please describe any specific goals you would like to achieve through participation in this program. *This question is required.

14. Do you have any interest and/or experience in volunteering for a professional organization such as AAPM&R? *This question is required.

15. Any additional comments you’d like to provide on the 2025 Resident Retreat?

Please attest to the following statements by checking each box:

16. Statement 1: *This question is required.

17. Statement 2: *This question is required.

18. Statement 3: *This question is required.

19. Statement 4: *This question is required.

20. Electronic Signature:
*This question is required.

Clear

Sign name using mouse or touch pad

Signature of

21. Today's Date: *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

22. Attach CV (Allowable File Types: png, jpg, jpeg, doc, docx, pdf):
*This question is required.

File: {{filename}} delete