Committee Volunteer Form
One of the greatest gifts you can give is your time.
Name
First Name
Last Name
E-mail
Please list your full name and credentials as it should be listed on the official documentation and website.
example: SarahAnn S. Whitbeck, MBA, FACEHP, CHCP
Please indicate which committee(s) you would like to volunteer for - and rank accordingly.
Committee Name
Ranking
Nomination committee
1
2
3
4
5
6
7
8
9
Development committee
1
2
3
4
5
6
7
8
9
Education committee
1
2
3
4
5
6
7
8
9
Research committee
1
2
3
4
5
6
7
8
9
Membership committee
1
2
3
4
5
6
7
8
9
Patient Education committee
1
2
3
4
5
6
7
8
9
Publications committee
1
2
3
4
5
6
7
8
9
Ethics Advisory committee
1
2
3
4
5
6
7
8
9
Database committee
1
2
3
4
5
6
7
8
9
Board of Directors
1
2
3
4
5
6
7
8
9
Please provide a short description about your qualifications for the above-noted volunteer role(s) and any prior volunteer/professional roles that demonstrate applicable skills. (Preferably at least 100 words)
By signing herein, I affirm the above information is accurate and complete.
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