MDVMA Power of 10 Participant Application 2023-2024

MDVMA Power of 10 Application
Expectations

It is imperative that participants’ employers are aware of and supportive of
participation in this program because of the time commitment, particularly
on weekdays.

The program mentors and the MDVMA executive director are always available to speak with employers or managers to help convey the benefits of participating in this program.

With your commitment, attendance and participation is considered mandatory.
Contact and General Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Veterinary school*
Graduation year*

2016201720182019202020212022Other
Area of Practice (select all that apply)*

Small AnimalAcademicExoticsGovernmentShelterFood AnimalEquineOther
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Hospital/Practice Name*
Employer's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Getting to Know You

This information will not be shared with anyone outside of the selection committee. Please be honest!
Why are you interested in participating in the Power of 10 Leadership Program? *

0/300
What do you hope to gain / what goals do you hope to achieve through participating?*

0/300
What life experiences or unique perspectives would you bring to the group that might benefit everyone?*

0/300
What areas of personal or professional growth are you most excited to explore? Feel free to share real life stories or examples.*

0/300
List of organizations, clubs and/or committees in which you have participated or held office (including undergrad and veterinary school).*

0/300
Your Signature - By signing you affirm that your responses are true and complete. *

Clear
Your Signature - By signing you affirm that you will fulfill the commitment as outlined in the program overview. *

Clear
Your Signature - By signing you affirm your employer/manager fully supports you in this year long leadership endeavor. Your employer/manager understands that you will be required to take 8-12 days off to participate in this program.*

Clear
Employer/Manager Name*

First NameLast Name
Your Employer/Manager Phone Number*
A member of the selection committee will contact you employer/manager to confirm support.
Applications are due to MDVMA by March 17, 2023
Should be Empty:

MDVMA Power of 10 Application

Contact and General Information

Getting to Know You

Applications are due to MDVMA by March 17, 2023