LEAP Online Entry Form

Name of Project

New project
Project on-going from previous year
If ongoing, (Project Bank # __ )

State project
County project
Resident Physicians'/Medical Students' Spouses Projects

Alliance Information:

Number of county Alliance members (if applicable)

Number of RP/MSS Alliance members

Number of state Alliance members

Number of national Alliance members

Number of county or state Alliance state PAC members

Number of county or state Alliance AMPAC members

County or state Alliance or RP/MSS group name

County or state Alliance or RP/MSS President's name

President's phone number

Contact name

Alliance position

Address

City

State
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Zipcode

Phone

Fax

E-mail address

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Project Description: All fields must be filled out to submit form.

Judges will refer only to your project description when reviewing your entry. Please do not refer to the name of your Alliance in the project description.

Project Summary
Provide an overview of your project, your target audience, highlights of the project, and whether or not any co-sponsors were involved. Limit 350 words.

Description of Goals
Briefly outline the project’s goals, what planning was involved, and who was responsible for the implementation of the goals. Limit 350 words.

Impact of Project on Legislative and Political Involvement
Describe and evaluate ways in which your project impacted legislative and political involvement among the participants and highlight all areas of success. Limit 350 words.

Effect on AMPAC and State PAC Membership
Describe and evaluate the effect this project had on membership in these organizations and highlight all areas of success. Limit 350 words.

Budget and Resource Summary
Provide an overview of the necessary resources, funds, donations, services, and volunteers needed to complete the project. Limit 350 words.