Louisiana YFA Committee

Louisiana YFA Committee
About You
Full Name*

First NameMiddle NameLast NameSuffix
Designation*

MDDOMD, FACSDO, FACSOther
Academic Program/Practice Name*
Email*
example@example.com
Cell Number*
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Membership Type*
Your Discipline*

General SurgeryTrauma/Critical CareBreast SurgeryVascular SurgeryTransplant SurgeryThoracic SurgeryCardiac SurgeryOtorhinolaryngologyOrthopedic SurgeryUrologyPediatric SurgeryColorectal SurgerySurgical OncologyPlastic SurgeryMinimally Invasive/Bariatric
Social Media
Social Media Platforms*

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Your Interest
Your interest (check all that apply)*

AdvocacyMock OralsChair a CommitteeServe on the Program CommitteeServe as a Chapter LiaisonSocial Media Takeover
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About You