application form - National Center for Family / Professional

AAP FamilY Partnerships Network – Executive Committee
The Executive Committee of the FamilY Partnerships Network (FPN), an advisory group to
the American Academy of Pediatrics (AAP) Board of Directors, is being expanded from 4 to
7 members. The FPN itself is transitioning to a broader role to fulfill the Board resolution to
“develop and implement a strategy to expand the opportunity for parent/family/youth
input and participation in AAP activities and programs.” Expectations are that the FPN
Executive Committee will include:
members who represent a diversity of interests and experiences
fathers, mothers, youth, guardians or other family members
members who are actively engaged in children’s health care
members who have both special or specific interests as well as broad, general
interests in the health and health care of children and families
members whose experience is at local community; and/or state; and/or national
members connected to parent/family/youth networks
members who believe collaboration with pediatricians and other professionals is
essential to quality child health
Members will be expected to:
attend two in-person national meetings per year (expenses paid)
participate on monthly conference calls
mentor other family/youth to participate in AAP activities
review and comment on proposed AAP policies and documents
actively participate in the work of the AAP, express family/youth viewpoints and
issues, identify resources and links to further family/youth resources
further the work of the FPN as goals and activities are developed
To Apply
If you would like to be considered for membership on the FPN Executive Committee please:
1. complete the application form below
2. write a few sentences regarding your interest and experience
Application materials should be submitted by January 5, 2015. Submissions and any
questions about this Call for Nominations should be sent to:
Sunnah Kim, AAP Staff
Phone: 847-434-4729
Fax: 847-228-8651
AAP FamilY Partnerships Network
Street Address:
City, State, Zip:
Email Address:
Phone Number:
1. Which best describes you? Check all that apply.
Youth/Young Adult – “Typically Developing”
Youth/Young Adult with Special Health Care Needs
Mother of Typically Developing Child(ren)
Father of Typically Developing Child(ren)
Mother of Child with Special Health Care Needs
Father of Child with Special Health Care Needs
Sibling of Child with Special Health Care Needs
Other (Please Describe):
2. Are you employed as a youth/parent/family member in an area of child health or family
resource and support?
If Yes, please indicate position and organization:
3. Are you or have you in the last 5 years been a participant or member of an AAP
Initiative, Advisory Group, Committee/Section/Council/Task Force/Special Interest
Group or other?
If Yes, please provide some additional information below:
Initiative/Group Name:
Role (eg., liaison, advisory, speaker,
reviewing/developing material):
Approximates dates of involvement:
4. Are you active in other local, state, or national pediatric activities?
If Yes, please check all that apply:
With a local pediatric practice
With a children’s hospital
With your AAP State Chapter
With your state Title V Program (State Health Department)
With a family or youth support organization or network
Other (Please specify):
5. What are your special interests and skills? Check all that apply:
Family-to-family or peer support/youth support
Child health financing
Child health policy
Child health and wellness
Education of families/youth or professionals
Emergency preparedness
Legislative advocacy
Medical ethics
Medical home
Mental health
Palliative Care/Hospice
Patient safety
Transition from pediatric to adult care
Specific condition or disability (please note below)
Special population groups (e.g., special health care
needs, Hispanic, Black, urban, rural, adolescent please note below in the Comments section.)
6. Please provide the name of a pediatrician who can serve as a reference, along with
contact information. (Your child’s personal pediatrician or a pediatrician you have
worked with.) Please let them know you are applying and that they may be contacted
regarding this application.
Pediatrician Name:
Email Address:
Phone Number:
7. Please provide a few sentences regarding your interest and experience and the unique
perspective you will bring to the FPN Executive Committee.