NCAFP Resident / Student Leadership Interest Form
Deadline to submit this interest form, your CV and letter of recommendation is May 31, 2019, 11:59 pm EST.

* If you are seeking a position, please be aware of required functions / time away from your program (noted below).
* Complete this form and email your CV to by 11:59 pm EST, 5/31/19.
* Submit a Letter of Recommendation - Residents must obtain this from your Program Director or Assistant PD - Students should obtain one from a FM dept. faculty member or advisor.

The LOR should speak to the qualities that would make you an effective leader, your interest & involvement in family medicine / leadership roles to date and a willingness to support your requests for time off to attend meetings. The NCAFP is aware they cannot guarantee granting time off but there should be a willingness to consider your requests for time away from clinic/rotations/classroom to fulfill your obligations.

Meeting dates for all positions have not been confirmed for Dec. 2019 - Dec. 2020; however what is known is listed. Specific time / days will be available at least 4 months prior to meeting - in most cases more notice than that will be provided.

Academy Board of Directors: DIRECTOR-ELECT - 1 student & 1 resident position - 2 year term, 12/2019-12/2021.

1) NCAFP Annual Mtg, Asheville, Sunday Dec. 8, 2019 - 8am - 11:30am
2) Spring 2020 Board Meeting, TBA - typically a Fri/Sat in April in the Charlotte area.

3) AAFP National Conference for Students & Residents in KC, MO: July 30 - Aug. 1, 2020 - Note: must be onsite no later than late Thurs. am to attend opening Congress session and stay thru Sat 1:00 pm for the final Congress session. Since NCAFP funds this position, delegate duties take priority over recruiting for your residency program. Residents can do both, but recruiting cannot supersede delegate responsibilities.

4) Summer/Fall Board mtg, likely in conjunction with the Foundation's FM Gala fundraiser - 8/22 or 8/29/2020 (Raleigh)
5) NCAFP Annual Mtg, December 3 - 6, 2020 (Thurs afternoon thru Sun noon required)

FOUNDATION BOARD OF TRUSTEES (2 positions for students / 2 for residents - 1-year term, 12/2019-12/2020):

1) Spring 2020 Board Meeting, TBA - typically a Fri/Sat in April in the Charlotte area.
2) NCAFP Annual Mtg, December 3 - 6, 2020 (Foundation meets Fri 12/4 - morning)

COMMITTEE REPRESENTATIVE (3 positions students / 3 for residents, 1 each per committee. 1-year term, 12/2019 - 12/2020). Meets twice yearly plus a likely conference call. For more detailed committee descriptions please refer to

1) Spring 2020 Board Meeting, TBA - typically a Fri/Sat in April in the Charlotte area.
2) NCAFP Annual Mtg, December 3 - 6, 2020 (Committee schedule varies, they meet anytime between Thurs 12/3 and Saturday 12/5 - schedule will be available at least 4 months out).

Please direct questions to Tracie Hazelett, Mgr., Medical Student & Residency Relations at 919-980-5357 or via

Email address *
I am currently enrolled as a *
First, Middle I., Last Name and Credentials *
Your answer
Mobile Phone# *
Your answer
Name of Medical School or Residency Program in which you are currently enrolled. *
Your answer
Anticipated Graduation Year *
Current City of Residence *
Your answer
I wish to be considered as a Candidate for: *
I am willing to consider additional roles as indicated: *
Statement of Interest *
Please write your statement of interest that includes the position you are most interested in, why you would like to serve and why you think you would be effective in that role. Please address your statement/letter to the NCAFP Executive Committee. If you prefer to submit it as a separate attachment please do so as Word document and email it when you submit your CV.
Your answer
Please check to confirm : *
Additional Documents *
By checking the boxes below you have, or agree to send the following items to: Tracie Hazelett at the NCAFP offices as indicated below. The LOR can come through you or directly from the author to me via email:
Full Name as Signature: *
Typing your Full Name in the Space Below represents your signature and agreement with responses provided in this submission. Please contact Tracie If you have questions or additional comments you wish to provide regarding your candidacy.
Your answer
Date *
A copy of your responses will be emailed to the address you provided.
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