Lifestyle Medicine Interest Group Application
Please complete this form to be considered for recognition as a Lifestyle Medicine Interest Group (LMIG) with the American College of Lifestyle Medicine (ACLM).
Email address *
Type of medical or health profession school (i.e. MD, DO, PharmD, RDN, RN, NP, PT, OT, PA, RT, AT) *
Your answer
Name of School *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Student leader name *
Your answer
Student leader email *
Your answer
Faculty/Staff name *
Your answer
Faculty/Staff email *
Your answer
Is this an established student group at your school or will you be creating a new group *
If group is already established, in what year was it established? (Skip if not applicable)
Your answer
In your opinion, what makes your school a good location to establish an ACLM recognized LMIG? *
Your answer
If approved, would you like grant funding to serve plant-based food at your first or next LMIG event? *
What resources or materials would you like developed for your LMIG?
Your answer
Terms of Agreement *
In order for a Lifestyle Medicine Interest Group (LMIG) to be recognized by the American College of Lifestyle Medicine (ACLM) the organization is required to comply with the following conditions: 1) Act in the spirit of evidence-based lifestyle medicine, as defined by ACLM’s Core Competencies and the Lifestyle Medicine Standards. 2) Host at least two student-oriented events per semester and one community-outreach event per year.Communicate updates with the ACLM Trainees executive board including contact information and new officer elections. 3) Submit fall and spring semester report forms by 11:59pm EST on December 15th and May 15th, respectively. 4) Maintain at least one LMIG student leader with an active ACLM student membership. 5) Connect with a faculty advisor who shares the spirit of lifestyle medicine and encourage them to be involved with ACLM. Any student organization who fails to operate within these conditions will be at risk of losing ACLM recognition and promotion as an official LMIG.
Required
Submit
Never submit passwords through Google Forms.
This form was created inside of American College of Lifestyle Medicine. Report Abuse - Terms of Service