2020 Spring Election Candidate Application

EPSIG Director Appointment | 1-Year

The EPSIG provides a forum to connect early-career PTs and PTAs (0-5 years of practice) from a variety of clinical disciplines that promotes networking and cross-leveling of information.

Objectives

Promote the Academy membership, events, opportunities and benefits
Increase and diversify educational resources for physical therapy professionals and the public
Encourage exchange of information relevant to the physical therapy profession and the respective special interest topics
Coordinate activities and campaigns to increase member and community engagement
Connect and engage with current and prospective members.

Eligibility: Candidates must be active Academy PT or PTA members for at least 1 year immediately preceding the appointment. Candidates may be in their 4th year of practice for this specific appointment. In all other years, when the position is a 2-year term, candidates would ideally be in their 0-3 years of practice when beginning their term.

Term: 1-Year Appointment (March 2021-February 2022). Your term would begin on March 8, 2021 at the General Business Meeting of the Academy of Pelvic Health Physical Therapy.

View additional position details at https://aptapelvichealth.egnyte.com/dl/jIqNUQzQQN/?

For inquiries, please contact our office at nomcomm@aptapelvichealth.org.

Part 1 of 3:

Consent to Serve Form

Full Name *

First Name Last Name

Designation / Credentials (i.e. PT, DPT, PhD) *

I am and have been a member of the Academy of Pelvic Health Physical Therapy for at least 1 year preceding appointment application. *

Yes No

I understand that, if elected, I may be expected to attend the Combined Sections Meeting, in-person and conference call board meetings. *

Yes No

YOUR INFORMATION

Your APTA Member ID *

This is your APTA Membership ID. If you do not know your ID #, please contact APTA at 800/999-APTA (2782) or memberservices@apta.org

Mailing Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Email *

Cell Phone:

Office Phone:

Home Phone:

I would like to be notified of election results by (Rank in order of preference. We will contact you by preferred method first):

I consent to the above statements (please, sign below): *

Clear

Part 2 of 3:

Candidate Position Statement Form

INSTRUCTIONS FOR NOMINATED MEMBERS: Please, fill out the following Position Statement Form. For reference, you may check out the Position Statement Sample linked here.

Education: *

Certifications: *

Current Practice (i.e. if Student, current aspirations or what you are currently involved in) *

Briefly describe your current practice

Professional Awards and Contributions *

150 words or less 0/150

Previous Involvement in the ACADEMY *

Previous Involvement in the APTA or State Chapter or other Sections: *

PERSONAL STATEMENT: Please address the following questions in 300 words or less: 1. What is your personal vision? 2. How would you lead the Academy (if SIG, the respective SIG)? Where do you feel the Academy is going (if SIG, the respective SIG)? Please note that this statement will be publicly shared with members during the elections, please make sure this statement is publication-ready. *

300 words or less 0/300

Upload a Professional Headshot: *

Upload a File

Accepted filetypes: jpg, jpeg, png, pdf, docx, doc only

Part 3 of 3:

Conflict of Interest Disclosure Form

Your Name: *

First Name Middle Name Last Name

Today's Date:

Month Day Year

Please describe below any relationships, transactions, positions you hold (volunteer or otherwise), or circumstances that you believe could contribute to a conflict of interest between the Academy of Pelvic Health Physical Therapy and your personal interests, financial or otherwise: *

I have no conflict of interest to report I have conflict(s) of interest to report

Please specify other nonprofit and for-profit boards you (and your spouse) sit on, any for-profit businesses for which you or an immediate family member are an officer or director, or a majority shareholder, and the name of your employer and any businesses you or a family member own):

I hereby certify that the information set forth above is true and complete to the best of my knowledge. I have reviewed, and agree to abide by, the Policy of Conflict of Interest of the Academy of Pelvic Health Physical Therapy. I understand that failure to disclose conflicts of interest may result in disciplinary action as outlined in the SoWH Governance Manual, and may include dismissal from the appointed/elected position or expulsion from the Academy.

Your Signature *

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Enter the message as it's shown *

After submitting, please check your inbox for a copy of your application.