2025 Resident Leadership Forum Nomination Form

2025 C. McCollister Evarts Resident Leadership Forum (RLF) Nomination Form

Please fill out the form below to nominate up to 2 PGY4 residents to attend the 2025 C. McCollister Evarts Resident Leadership Forum in Minneapolis, MN. The deadline to nominate is Thursday, January 31, 2025.
Nominator

*Must be a Program Director or Department Chair*
Nominator Name*

First NameLast Name
Nominator Email*
example@example.com
Position Title (Program Director or Department Chair ONLY)*

Program DirectorDepartment Chair
Institution*
Institution (If selected Other)
Nominee #1
Name*

First NameLast Name
Email*
example@example.com
Nominee #2
Name

First NameLast Name
Email
example@example.com
Confirmation of Fees and Nomination
I understand that my institution is responsible for the registration fees and any expenses related to travel or lodging for my nominee(s).*

Yes
I understand that by completing this form I have made a nomination only. I understand that my institution's nominee(s) must register to attend the C. McCollister Evarts Resident Leadership Forum.*

Yes
I am confirming I have nominated a PGY4 to attend the C. McCollister Evarts Resident Leadership Forum.*

Yes
Nameplate Mailing Information

Upon attendance of the 2025 RLF, your nominee(s) nameplates will be mailed to their respective institution in October/November. Please advise where and to whom these should be sent to.
Mailing Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Mailing Instructions:
Should be Empty:

2025 C. McCollister Evarts Resident Leadership Forum (RLF) Nomination Form

Nominator

Nominee #1

Nominee #2

Confirmation of Fees and Nomination

Nameplate Mailing Information