N.C. ACADEMY OF FAMILY PHYSICIANS FOUNDATION, INC.
Family Medicine INTEREST ProgramS - Student Application
Participation and Preceptor matching is directed by information provided below. Application, autobiographical sketch and current curriculum vitaepackagemust be postmarked or received via fax or email by 11:59pmJanuary 15, 2015.Applications received after that will not be considered. You will be notified in March regarding your acceptance into a program. Please complete this form electronically.
Date: ______
Please Check All Programs forwhichPlease Rank your Order of Preference 1 - 3:
you wish to be considered:
Rural Health Program – Eastern Rural Health Program Eastern______
Rural Health Program – Western Rural Health Program Western ______
NCAFP Externship Program NCAFP Externship Program______
Name: ______
Current Mailing Address:______
Street CityZip
Phone:______Hometown / State:______
E-mail address #1: ______E-mail #2______
U.S. Citizen? Yes No Sex: M F DOB: ______Medical School attending: ______
Legal resident of which state?______How long have you lived in NC? ______Which NC County have you lived in longest? ______
Emergency Contact: ______Phone:______
______
Street CityStateZip
Educational Information
______
Undergraduate SchoolName CityStateDegree(s) received
______
Graduate School NameCityState Degree(s) received
Member of the Academy?
Yes No If not, please complete application to join by January 15th in order for your application to be considered (it’s FREE)
Preceptor, Practice & Geographical Location Preference
In general Family Physicians see the spectrum from newborn to the elderly; however, if you have a particular area of interest please specify. Preferences are helpful but cannot be guaranteed.
Preceptor Preference: Male Female Minority No preference
Practice Preference: Group Solo Rural Urban Other underserved No preference
Special interests: Pediatric Adolescent Geriatric Sports Medicine Behavioral Health
Other ______ Healthcare Policy / Advocacy Woman’s Health Obstetrics
Geographic Preference: Please list your first, second, and third choices of regional preferences. This will be considered but cannot be guaranteed when making placements. If you have extenuating circumstances please note below: ______
1st choice: Western Piedmont/Triad Charlotte Triangle South Central/Eastern Coastal
2nd choice: Western Piedmont/Triad Charlotte Triangle South Central/Eastern Coastal
3rd choice: Western Piedmont/Triad Charlotte Triangle South Central/Eastern Coastal
For the purpose of host home assignments please note the following:
Pet / Animal allergies: None As follows: ______
Dietary Allergies / Restrictions: None Vegetarian Other: ______
Other Environmental / Placement Considerations: ______
Clinical Externship Timeline: To be completed if applying for the 4-week Clinical Externship. Please listdates of availability taking into account vacation, other jobs, scheduled or anticipated travel. If only applying for the Rural Health Experience dates are NOT flexible and you do not need to complete this section.
Notes: 1) you don’t have to do 4 weeks consecutively; you can split the experience into segments 2)scheduling modifications aremade for Duke medical students due to shortened summer break. Please note: ALLtime periods AVAILABLE:______
______
Will you receive any stipend or reimbursement for this externship other than the one provided by the NCAFPFoundation? Yes No
If “Yes”, please list source & amount of stipend or reimbursement: ______
Autobiographical Information
Please submit an autobiographical sketch with your completed application and CV. This information will be utilized by the selection committee and also shared with your Preceptor. Please consider including the following information (order not relevant):
- Personal information that you may find pertinent to your education and career choices, specifically how they relate to Family Medicine
- What influenced you to enter medical school?
- Describe your community involvement
- Describe leadership positions / opportunities
- What are your future professional and personal goals?
- Describe experiences that you have had in health care or research that have impacted you.
- What are your major interests outside of medicine?
- What characteristics do you possess that you think will make you a physician? What about a good family or primary care physician?
- What are your expectations regarding your participation in one of these programs?
Participation Acknowledgement forNCAFP FoundationFamily Medicine Interest Programs
Faculty Pre-Doc Director or Faculty Advisor Signature
Each applicant is required to meet with their school’s Director of Medical Student Education in Family Medicine and/or Faculty Advisor to gain additional insight into the Programs and to confirm their interest and application prior to submission.
______
Name of Faculty (please print)Signature of Faculty Date
______
Phone numberE-mail address
By January 15, 2015, send this signed application, autobiographicalsketch & CV as a package to:
Tracie L. Hazelett, Family Medicine Interest Programs
Mail: NCAFP Foundation, PO Box 10278 Raleigh, NC 27605 or Fax: 919-833-1801 or Scan:
For additional information please call or e-mail: 800-872-9482 or
NCAFP Foundation Programs Available to First-Year Medical Students
The North Carolina Academy of Family Physicians Foundation offers a variety of programs and opportunities to medical students. A few of these are clinical experience opportunities only available to 1st year medical students. These opportunities take place during the summer between your first and second year of medical school.You do not have to be convinced that the specialty of Family Medicine is your career path; you must merely have an interest in learning more about this exciting specialty.There are two programs available offering insight and clinical experience in Family Medicine. Deadline for both programs: January 15, 2015.
Rural / Underserved Health Experience - 2-week immersion experienceOne in rural Eastern and one in Western North Carolina. Each program will accommodate up to ten students.
The Western NC programwill be held May 31 - June 13, 2015 and the Eastern program will be held July 19-August 1st, 2015. While the programs will differ in some ways due to geography and the nature of the underserved areas in which they are located, they will be similar in other ways. The first week will take place with 8-10 other NC medical students at a residency training program where students will participate in various activities which may include a day in the life of a rural family doctor, wilderness medicine day, rural health topics didactic sessions, visits to a rural hospital, a rural health department and information regarding resources (loan repayment, etc.) available to those who choose to practice in a rural or underserved area of NC. The 2nd week you will be matched with a practicing family physician to spend a week in the life of family doctor working in a rural / underserved area. Additional information can be found on NCAFP website:
- Student comments: I have loved the physicians I’ve been able to work with over the past two weeks. I have learned a LOT about what life is like both in the clinic and out (thanks to our physician hosts& interactions with residents) for a rural physician. My mind is full of colorful stories I’ve heard, faces I’ve seen and the enthusiasm to explore this area of medicine further. It makes me excited for the years ahead.
NCAFP Externship Program - 4-week clinical experience: Dates are flexible. Designed to offer students the opportunity to work alongside a practicing community family physician to see first-hand the daily life and activity of a full time, community – based practicing physician. Depending on the physician paired with, experiences may involve daily patient care, hospital rounds, nursing home or group home care visits, hospice care, free clinic work, house calls; it will vary according to the physician and community. Every effort is made to pair students in the geographic area of choice, however not all specific locations can be accommodated so flexibility is requested.
- Student comments: “This experience provided very practical, hands-on learning that helped me “connect-the-dots” between classroom learning and on-the-ground experience.” “Great opportunity to practice interviewing & physical exam skills…it helped me become more comfortable with this skill.” “I loved the change from treating a six-month old baby for a well check, to a 52 yo man with high cholesterol. The ongoing patient relationships helped me understand how to better council patients and ultimately manage their health issues.”
Aprimary goal of these programs is to provide students with community-based experiences, opportunities away from the academic setting. Therefore, each experience offers a travel / housing stipend to help off-set commuting and/or housing costs you incur as a result of your placement. Please note AHEC housing does partner with us and helps us whenever possible but due to 3rd year clerkship students the housing in specific areas may be filled.