Media Relations Sign-Up Form

Media Relations Sign-Up Form
Name*

First NameLast Name
Credentials (MD, DO, FAAFP?) *
Additional certifications or degrees*
Email*
example@example.com
Location*

CityState / Province
Practice Name
Professional Title
Cell Phone Number
Please enter a valid phone number.
I am interested in:*

Replying to media requests for IAFP for scheduled interviews by Zoom or other virtual platformWriting a letter to the editor for my community paperParticipating in live options, such as group press conferencesLive radio or TV (by phone, in studio or via Virtual platformPodcastsSocial media
Please check all days of the week that you can possibly participate in Media opportunities.

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Preferred Time of Day: Additional information such as mornings, lunch time or a particular time of day such as after 5pm
What media experience do you have?

NoneInterviewed with print or online mediaTV interview (recorded)Live TV or RadioLetter to the editorPodcast interviewPress conference participantOther (include description in the next question box)
Please list the topics you are most interested and/or areas of expertise.*
Upload a recent Head shot photo

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Thank you for your submission. IAFP will contact you if we receive a request that fits your expertise. You can also contact Ginnie at gflynn@iafp.com to request assistance with any media requests that you receive outside of IAFP.
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