LEADERSHIP INTEREST FORM - American Academy of Pediatrics




THIS FORM CAN ALSO BE FOUND AT: http://www.aap.org/ypn/r/leadinterestform.pdf

Name: Training Program:


Telephone (Day):


Year of residency training or fellowship training:



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


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