SAO/SWSO 2024 Leadership Program Application
The purpose of this program is to provide a learning experience for individuals interested in developing leadership skills. These skills will be valuable in all kinds of leadership situations within practices, church groups, civic organizations, study clubs and dental societies.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Cell Phone Number
-
Area Code
Phone Number
Please provide us with a photo of yourself.
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1. Where do you practice (city, state-we know it might be more than one)?
2. When did you graduate your Residency?
-
Month
-
Day
Year
Date
3. What is your practice modality?
Solo Practitioner
Multiple Practitioners
Corporate Dentistry
Education
Multiple-I work in multiple offices
Other
4. How did you hear about the Leadership Program?
Word of mouth
Presentation at a state association meeting
Print or digital media
Other
5. Can you certify that you will be able to attend all 3 sessions below? January 17, 2024 Zoom Call, 7:00pm ET; Friday-Saturday, March 8-9, 2024 Nashville; Wednesday, September 25, 2024 Orlando.
Yes
No
Not certain
6. Why do you want to participate in the Leadership Program?
7. Please list your current professional and civic/community involvement(e.g. AAO, dental assoc., Kiwanis).
8. What are your expectations of the Leadership Program?
10. Are there any particular topics for presentation by the SAO/SWSO Leadership that you are most interested in hearing?
11. A portion of the programing is dedicated to a group research project. The goal/benefit is to identify opportunities the association can enhance its member benefits or areas the association should dedicate additional research/development. Recent projects have included practice opportunities, do-it-yourself orthodontics, membership target market communication. Do you have any suggestions for group research projects to be conducted by Program participants?
12. What are you favorite hobbies and pastimes outside of work?
13. Any final thoughts you would like to convey?
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