Heart of Family Medicine Award
2026 Nomination Form
This award honors an individual-either a family physician or a community member-whose work embodies the spirit and mission of family medicine through exceptional service to underserved populations, impactful community outreach, or advocacy that elevates the specialty. Whether through direct patient care, legislative work, public engagement, or media efforts, the recipient demonstrates a deep commitment to improving the health and well-being of Arkansans.
Submit by July 1
NOMINEE INFORMATION
First Name
Last Name
Employer/Organization
Email Address for Nominee
example@example.com
Nominee Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Eligibility Confirmation - This nominee is (check all that apply):
Nominator Information:
Your Name
First Name
Last Name
Your Email:
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Nominee:
Nomination Questions
Please answer the following questions to help the committee evaluate the nominee:
Briefly describe how the nominee has demonstrated a deep commitment to the health and well-being of Arkansans.
How has this nominee served underserved or vulnerable populations, or advocated for the specialty of family medicine? (Include examples such as community service, legislative support, media work, etc.)
What impact has their work had on the visibility, understanding, or advancement of family medicine in Arkansas?
Supporting Materials (optional but encouraged) You may upload Letters of Support, Media Samples (news articles, links, recordings, etc.), Examples of community work, programs or legislative work.
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Thank you!
Questions: Contact Mary Beth Rogers at mary@arkansasafp.org
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