FAMILY MEDICINE INTEREST PROGRAMS: 2019 application for N.C. Academy of Family Physicians Foundation summer programs
NOTE: If you are applying TODAY, 1/15/19 - and you have questions - please be aware I (Tracie) am on the road until this evening. If you have an urgent question or need, texting me will result in a more timely response (919-210-7409). Otherwise, please proceed with submitting your application to ensure a timely submission and I will follow up with you accordingly. Or email me and I will reply this evening.

Before proceeding, please be aware the information you provide is the only thing the selection committee has available to them. While we do not want this to be a cumbersome process, please be thoughtful in the information you provide and take the time to proof-read the information you submit.

Participation and Preceptor matching is directed by the content within this application. This form, including the autobiographical statement, and a current curriculum vitae (NO more than 2 pages) must be submitted by 11:59pm January 15, 2019.

In order for your application to be considered, you must be a member of the American Academy of Family Physicians (AAFP), and therefore a member of our state chapter, the NC Academy of Family Physicians (NCAFP). If you are not, please join asap at: www.aafp.org/join

If you have questions before getting started or at any point during the application process please contact Tracie Hazelett: via e-mail: thazelett@ncafp.com, voice: 919-980-5357 or text: 919-210-7409.

Thank you for your interest!
Tracie

NOTE re: your autobiographical statement. Your autobiographical / interest statement can be a modified version of your medical school application statement. However, please do modify it; reviewers notice when you do not take the time to do so.

Suggestions for items to include for these programs are in the description of where you insert your statement. Please read, the review committee is looking for this content as they review applications.

I suggest you create your statement in a word document prior to beginning this application, then copy / paste in the designated area below. Typical length varies but most range between 700 - 1400 words (1-2 pages). Since we are not able to conduct personal interviews, this is the primary source of information available to the review committee.

NOTE re: Curriculum Vitae. Your CV should be no longer than 2 pages and must be submitted via email to Tracie by the deadline of 11:59pm on January 15th. Word Document preferred. Anything beyond 2 pages will not be provided to the committee for review.

Eastern Rural Health Program: Two weeks, June 9 - 22 - beginning on a Sunday - ending on a Friday (time off on the wknd in between from Fri. evening 6/14 thru Sun. 6/16 afternoon/eve).

Western Rural Health Program: Two weeks, July 7 - 20, 2019 - begins Sunday afternoon; ends Friday close of clinic. You should plan to remain the entire 2 weeks, housing is provided continuously thru 7/20. However you do have free time Sat. a.m., 7/13 thru Sun. 7/14 afternoon if you need to leave for a previous commitment (wedding, etc.)

Four-Week Clinical Externship: Flexible dates based on you / your preceptor's schedule - PLEASE NOTE: if accepted into this program, we are fortunate enough to receive some matching funding from the AAFP Foundation, you will be expected to complete a brief post-experience survey for the AAFP in addition to the one you complete for the NCAFP.

www.ncafp.com/students/summer

Email address *
First Name *
Your answer
Middle Name (or initial) *
Your answer
Last Name *
Your answer
The Program I am MOST interested in participating in is: *
My second choice is: *
My third choice is: *
Date of Birth:
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Sex: *
Answers do not affect consideration given to your application. Information provided will be considered when making host home assignments in the rural programs.
Secondary Email (required) *
Different from the first one you provided. At least one of the emails you give must be a "permanent" email that is NOT AFFILIATED with your school, i.e. a Gmail account.
Your answer
Mobile Number: *
Your answer
Medical School: *
Please note your last day of exams/classes for this M1 year: *
MM
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DD
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YYYY
Please note your first day of classes for M2 year: *
MM
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DD
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YYYY
Current Mailing Street Address *
Please use your personal, LOCAL address, not your parents or other address you might consider more permanent.
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
U.S. Citizen? *
Legal resident of what state? *
Your answer
How long have you lived in North Carolina? *
Emergency Contact Name AND Relationship: *
Your answer
Emergency Contact COMPLETE Address: *
Your answer
Emergency Contact Phone Number: *
Your answer
Undergraduate Education: *
Please indicate NAME, CITY and STATE of academic institution as well as DEGREE received
Your answer
Graduate Education:
If you have a graduate degree, Please indicate NAME, CITY and STATE of academic institution as well as DEGREE received
Your answer
Preceptor / Practice Preferences: *
Please check if you have preferences. Note, attempts are made to accommodate requests but cannot be guaranteed.
Required
Interest areas *
In general Family Physicians see the spectrum from newborn to the elderly; however, if you have a particular area of interest please specify. Preferences are helpful but cannot be guaranteed.
Required
Geographical Preference - First Choice *
If you are requesting to participate in the Externship Program you should check regions in which you have housing available. Sometimes AHEC housing is an option but it cannot be guaranteed; therefore, consideration should be given to regions in which you have family or friends. Although this section is most applicable to the externship program it can also apply in special circumstances to the Western or Eastern program.
Geographical Preference - SECOND Choice *
Geographical Preference - THIRD Choice *
Please use the space below to further explain any preceptor, practice or geographical preferences as noted above.
Your answer
Allergies or Special Considerations *
For the purpose of host home assignments in the Eastern and Western programs please note the following:
Required
If needed, please explain any animal, dietary or environmental considerations
Your answer
Timeline for Four-Week Clinical Externship *
If you are not interested in the externship program; please write N/A below and move to the next question. If you are applying for the 4-week externship program, list all date ranges of availability. The greater your flexibility the better the chances of matching a preceptor with your geographical and / or interest area(s). Note: You don’t have to do 4 weeks consecutively. Scheduling modifications can be made for Duke medical students due to shortened summer break. Please note ALL time periods available.
Your answer
Other Summer Commitments *
Many students participate in NCAFP programs in addition to other summer activities. This is very do-able and we work with students as schedules become confirmed. However, if you already know of research, mission trips, personal travel commitments, etc. it is helpful to know up front. Please list them - and the dates if known - below. As dates become confirmed or other activities are arranged in the months following submission of this application, please send a message to Tracie to keep her informed. This is not communicated to the selection committee and does not affect your chances of program offers. It is merely important, helpful information.
Your answer
Other Comments
Please use this space if there is anything else you would like to further explain, clarify or offer for consideration within this application.
Your answer
Physician contacts *
Please provide the name, phone # and e-mail address of TWO physicians (at least one in the FM dept. at your medical school preferred). These should be faculty or physician mentors that know you as a person/student - they do not need to know your GPA, class rank, etc. These individuals will serve as more of a character reference in case NCAFP Staff have questions or need more information.
Your answer
Participation Acknowledgement And Release and Waiver From Liability *
All selected participants will be expected to sign a waiver form once program offers are extended. However, at this time please review the below, by checking the boxes and electronically signing (further below) you are indicating your understanding of the following:
Required
Autobiographical Information / Interest Statement *
Typical length varies but most range between 700 - 1400 words (1-2 pages). Since we are not able to conduct personal interviews, this is the primary source of information available to the selection committee. This information will be utilized by them and also shared with your Preceptor should you choose/be selected to participate. Information to consider includes: • Personal information you feel is pertinent to your education and career choices, specifically how they relate to family medicine/primary care • Influences to enter medical school • Community involvement • Leadership positions you have held /opportunities to lead • Future professional and personal goals • Describe experiences you have had in health care or research that have impacted you • Interests outside of medicine • Characteristics you possess that you think will make you a great physician • Your expectations regarding participation in one of these programs.
Your answer
I understand submitting my CV is necessary to complete my application *
CV should be 2 pages MAXimum as a WORD Document (no PDFs please); anything beyond 2 pages will not be provided to the review committee. Please edit accordingly then email to thazelett@ncafp.com
Your typed full name below serves as your signature *
Your answer
A copy of your responses will be emailed to the address you provided.
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