Student Committee Chair

Application Form

STUDENT COMMITTEE CHAIR

Instructions: Submit this completed application form and a résumé to by April 30, 2016. Include the phrase “Student Committee Chair” in the subject line of the e-mail with the application form and résumé attached. The PHCNPG Executive Committee is responsible for selection of the Student Committee Chair. Each applicant will be considered based on commitment to the position, experiences and strengths as related to the needs of the position, and overall impression. The applicant may be contacted fora phone interview if further information is needed. Applicants will be notified by May 31, 2016 to serve from June 1, 2016 – May 31, 2017.

Name: ______

Address: ______

______

Phone: ______E-mail: ______

Expected Date of Graduation/Program Completion: ______

Academy Member #: ______Years as an Academy Member: ______

Are you a current PHCNPG Member? ____ Yes ____ No

How long have you been a PHCNPG member?______

The Student Committee Chair is expected to attend monthly PHCNPG conference calls, as your schedule allows. Are you willing to participate in monthly calls? ____ Yes ____ No ____ Maybe

If you are unwilling to participate in monthly calls, please provide a brief explanation: __

______

Are you able to attend FNCE® (October 15–18, 2016)? ____ Yes ____ No ____ Maybe

If you are not able to attend FNCE®, please provide a brief explanation:______

______

Explain why you are interested in this position, what you hope to gain from the experience and what strengths and skills you will bring to the position. Please provide specific examples of strengths that you believe would fit the needs of the Student Committee Chair position (refer to the Position Description that is posted on the Student Members page for details). (500 words or less)

Please provide contact information for two professional references.

Name: ______Name: ______

Job Title: ______Job Title: ______

Institution: ______Institution: ______

Phone: ______Phone: ______

E-mail: ______E-mail: ______

Verification of Student Status

______is a student and will be enrolled in the program or

(Name of Student)

coursework a minimum of four months during the August 2016 – July 2017academic year.

______

Signature of Program Director/Academic AdvisorDate

______

Printed Name of Program Director/Academic Advisor

Institution:______

Phone:______

E-mail:______

NOTE: If you are in the process of computer matching for a dietetic internship, you may provide us with a copy of confirmation of acceptance into a program following Match Day as verification of student status.

1

Approved 2/14/2014

Revised 5/12/2014, 2/8/2015, 1/20/2016