Steps:

 

AMA-YPS Community Service Nomination Form

Nominations must be received by April 30.

Instructions
Please complete this form. Note that some supporting materials must also be mailed to the AMA Department of Young Physician Services, 515 N. State Street, Chicago, IL 60654, emailed to yps@ama-assn.org or sent via fax, (312) 464-5845 Attn:YPS

The information you provide below is solely for the AMA's internal use and will not be resused or sold for any commercial purpose without your permission.

Community Service Activity

*
Denotes a required field
Project Title
 

Project Description
Describe the community service activity in 150 words or less. Include information on the concern or issue the activity addressed, the project’s goal(s), target audience, and project duration. Attach (or mail) copies of any materials produced, and articles or news releases describing the project. If the program was evaluated in any way, include a copy of the evaluation data.

Project Description
 

Rationale
In 75 words or less, please indicate why you believe the project described above merits an AMA-YPS Community Service Award.

Rationale
 

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AMA-YPS Community Service Nomination Form

Nominee Information

*
Denotes a required field
Nominee
*
Name of Program, Organization, or Individual nominated
Address
*
Address Line 2
 
City
*
State
*
ZIP Code
*
Phone
 
000-000-0000
E-mail
 

Your e-mail address will not be shared, sold, traded, exchanged or rented. See our Privacy Policy for more information.

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AMA-YPS Community Service Nomination Form

Information on Person submitting nomination

*
Denotes a required field
Name
*
Address
*
Address Line 2
 
City
*
State
*
ZIP Code
*
Phone
 
000-000-0000
E-mail
*

Your e-mail address will not be shared, sold, traded, exchanged or rented. See our Privacy Policy for more information.

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AMA-YPS Community Service Nomination Form

Letters of Support

*
Denotes a required field

Letters of Support.
If you received any letters of support or have other information you would like to have the AMA-YPS Governing Council review, summarize below and send a “hard copy” to the AMA Department of Young Physician Services, 515 N. State Street, Chicago, IL 60654; or fax to (312) 464-5845, Attn: AMA-YPS.

You may contact the Young Physicians Section via e-mail at yps@ama-assn.org.

Summary of Support
 

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