AAFP Family Medicine Congressional Conference 2017
Application for Resident Scholarship

Deadline: February 10, 2017

AAFP Family Medicine Congressional Conference

2017 Dates/Location: Mon., May 22 – Tues., May 23. Washington Court Hotel, Washington, D.C.

In two days, learn about the legislative process, current priorities for family medicine, gain valuable advocacy skills and apply them during meetings with members of Washington’s Congressional Delegation.

The WAFP will award oneresident with up to $1500 to support their attendance to the AAFP Family Medicine Congressional Conference. Receipt of the scholarship obligates the resident to attend lectures, workshops, and meetings on the Hill. In addition, scholarship recipient must submit a letter summarizing his/her experience along with the WAFP reimbursement form and original receipts.

Application process:

  • Complete the form below
  • Answer essay questions on the back of this page
  • Sign attestation statement at bottom

• Signed Residency Program Recommendation Form (download online)

Please return completed application WAFP office. You may submit the application by e-mail to , by fax to 425-747-3109, or by mail to: 1239 - 120th Ave. NE, Suite G, Bellevue, WA 98005

Resident Name

Street Address

CityState/Zip

Phone AAFP ID#

E-mail

Residency Program: (circle one): PG1 PG2 PG3

Please provide the information requested below: (Attach a separate page if needed)

  1. Are you currently active in health policy development or advocacy activities with the WAFP/AAFP, or were you active as a student?If yes, please explain what activities you are/were involved in and why you are interested in them.
  1. What federal legislative issues do you believe most affect family physicians and their patients, and why?
  1. What do you hope to gain from attending the Family Medicine Congressional Conference?
  1. How did you learn about the scholarship opportunity?

To be considered a candidate for WAFP leadership/scholarship positions, or for WAFP Foundation scholarships, stipends or grants, the applicant must be a resident member in good standing with the WAFP and AAFP, must be duly licensed to practice medicine in the State of Washington, and in good standing with his/her residency program. All applicants must complete and sign the attestation statement below.

I attest that I am a resident member of the AAFP/WAFP; I am duly licensed to practice medicine in the State of Washington, and I am in good standing with my residency program at . If I become aware of any potential challenges to my resident status, it is incumbent upon me to notify the WAFP President or Executive Vice President.

Signature: Date: