ACGC Volunteer Application
Name
First Name
Last Name
Email:
example@example.com
Location:
Age:
18-25
26-33
34-41
42-49
50-57
58-65
66+
Age:
Race:
Indigenous American or Alaska Native
Asian
South Asian
SWANA
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer
Gender identity:
Female
Male
Non-binary
Prefer not to answer
Disability
Yes
No
Prefer not to answer
Select a committee or the committees you are applying to serve on
Nominating Committee
Communications Committee
DEIJ Committee
Program Review Committee (PRC)
Standards Committee
Finance Committee
Select a committee you are applying to serve on.
Please Select
Nominating Committee
Communications Committee
Standards Committee
Program Review Committee (PRC)
Applying to both committees
GC Education/Training (Graduate Program, Degree, Completion Date):
Current employer(s), position title(s), number of years at current position(s):
Practice Area:
Honors (include dates)
Please list your professional activities that may include Teaching/Mentorship/Clinical Supervision/Leadership Activities (within the last 5 years)
Please list your relevant experience for the committee(s) you are applying to serve on:
Please upload your CV (does not exceed 2 pages)
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Essay questions. Please do not exceed two paragraphs for each question.
Have you served on the PRC before?
Yes
No
If yes, when was the last review you participated in?
Serving on the PRC could require travel if you are part of a Site Visit. Are you willing to travel?
Yes
No
Depends on the location
What program(s) do you have a Conflict of Interest with? Conflicts of interest include: former student of the program, working directly (faculty) or indirectly (clinical supervisor) with the program, etc.
*
What knowledge and/or skills do you have that are a good match for the committee(s) you would like to serve on?
What knowledge, skills, abilities do you have that are a good match for the DEIJ committee?
What lived experiences or perspective do you have that may prepare you to work as an advocate for DEIJ in genetic counseling accreditation?
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