FM Champions Volunteer Sign up Form

Volunteer Sign up Form

Simply visit a local high school or undergraduate university health careers interest group/club near you! Link to all the helpful fact sheets provided by AAFP and share your own personal journey to medical school and family medicine. Please use this reporting form so we can record our impact in Illinois.
Name*

First NameLast Name
Degrees
E-mail*
Medical School
Graduation Year
Residency program (if applicable)
Practice or work name (if applicable)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Are you volunteering an Organization/Group Volunteering?*

Yes, a group effortJust me as an individual
Your Company/Group/Organization/
When did you present or plan to present to a group?

MonthDayYear
Date
Where did you present FM Champions?
Provide a short summary (group type, how many in the audience, topics they were most interested in?)
Please share any photos, videos, or other resources if you can!

Browse Files

Cancelof
Should be Empty: