Gerald R Gehringer Family Medicine Award

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Gerald R. Gehringer Family Medicine Award
Nomination Form

Name of person completing this form: *

Email address *

Phone Number *

Nominee Information

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Email address *

Cell Phone Number *

Medical School Information

Medical School Name *

Address *

City *

State *

Zip Code *

Date of Graduation: *

Did the nominee match in a Family Medicine Residency? *

Yes

If yes, what program, city and state.

If no, what specialty, program, city and state.

Is the medical student an LAFP member? *

Yes

Please describe how the medical student exhibits the following criteria:

How has the medical student shown evidence of active student leadership in family medicine activities? *

How has the medical student participated in a Family Medicine Interest Group or club and/or has participated in family medicine activities at the state or national level? *

How has the medical student shown scholarly accomplishments in his/her medical school courses by the development of a research project or publication of a scientific paper? *

How has the medical student shown scholarly accomplishments in his/her medical school courses other than family medicine? *