SECTION ON MEDICAL STUDENTS, RESIDENTS, AND FELLOWSHIP TRAINEES
LEADERSHIP INTEREST FORM
THIS FORM CAN ALSO BE FOUND AT: http://www.aap.org/ypn/r/leadinterestform.pdf
Name: Training Program:
Address:
Telephone (Day):
E-mail:
Year of residency training or fellowship training:
Fax:
(Evening):
Are you in a combined training program? (Please identify):
AAP Membership Category (check one)
**Note - you cannot run for office if you are not an AAP member
Resident Member: _ Fellowship Trainee Member: ___
I am interested in being considered for a national office appointment:**
Vice Chairperson (3-year):
Secretary (1-year):
District Coordinator (1-year):
Assistant District Coordinator (1-year):

Please note: You must be present at the National Conference and Exhibition (NCE) in Boston, MA in order to run for
Secretary, Vice Chairperson, District Coordinator or Assistant District Coordinator. Applications for the above positions are due by September 23, 2011. You may still run for a position if present at the NCE. However, preference
will be given to those that apply by the September 15 deadline.
I am interested in being considered for a 2-year liaison appointment (1/1/12 to 12/31/13):

Please note: you can still run even if you will not be a resident or fellowship trainee for the last 6 months of your term.
_____ Committee on Federal Government Affairs
_____ Committee on Pediatric Research
_____ Committee on Residency Scholarships
_____ Community Access to Child Health (CATCH)
_____ Council on Clinical Information Technology
_____ Council on Community Pediatrics
_____ Section on Adolescent Health
_____ Section on Breastfeeding
_____ Section on Child Abuse and Neglect
_____ Section on Early Education and Child Care
_____ Section on Emergency Medicine
_____ Section on Home Care
_____ Council on Pediatric Subspecialties
_____ Section on Administration and Practice Management
_____ Section on International Child Health

Liaison Appointments will be made following the National Conference and Exhibition by the Section on Medical
Students, Residents and Fellowship Trainees Executive Committee.
If you are interested in any of the positions listed above, please return this form with the following:
1) CV – one page summary**
2) A brief statement of interest – one page **
** For the national office appointments – this information will be shared with those in attendance at the NCE SOMSRFT
Assembly.
Barb Miller, Young Physicians Program Assistant
American Academy of Pediatrics
141 Northwest Point Blvd, Elk Grove Village, IL 60007
E-mail: bmiller@aap.org
Fax: 847/228-7035