NCCL Delegate Form

Connect with Us:

≡Open menu

HOME
PHYSICIANS
RESIDENTS
MEDICAL STUDENTS
Log In

Louisiana Delegate Application
National Conference of Constituency Leaders

Thank you for your interest in representing Louisiana at the National Conference of Special Constituencies. Please complete and submit the application and an LAFP staff person will contact you. Thank you!

Applicant

First Name *

Last Name *

Designation (MD/DO) *

Email address *

Cell Phone Number *

Address *

City *

State *

Zip Code *

Practice Type *

Solo

Employed

Small group

Physician-owned

Other

Please select which constituencies you would like to represent: (Note: You must meet the AAFP's definition for the contituency of your choice(s). *

Women

International Medical Graduate (IMG)

New Physician - (practice less than 7 years)

BIPOC - (African American, Asian, Native Hawaiian or Pacific Islander, American Indian, Alaska Native, ethnic Latino, other)

LGBTQ+ or Ally - (self-identifies as LGBTQ+ or who is supportive of LGBTQ+ issues)

If you choose more than one constituency above, please note which constituency you are most interested in representing: *

Have you attended NCCL in past years? *

Yes

If yes, when and in what capacity? *

Why are you interested in applying to be a Louisiana delegate to NCCL? *

The Academy seeks to appoint a delegation that can represent the diversity of LAFP's membership. Are there any other identities or skills that are important to you that you would like to share? *

The Academy also seeks to mentor member in their leadership skills. If selected as a delegate, would you be willing to be mentored to run for a leadership position while at NCCL? *

Yes

Louisiana Academy of Family Physicians
919 Tara Boulevard
Baton Rouge, Louisiana 70806

Phone: 225.923.3313
Fax: 225.923.2909

Email: info@lafp.org

Member Login

Username

Password

Remember Me

Forgot your password?
Forgot your username?