Board Interest

Board Interest Submission

Thank you for your interest in elevating the future of medicine with us. Please take a moment to complete this form so we can learn a little more about you.

Submissions are reviewed May and November with new board member service beginning June and January. If selected for consideration, someone from the organization will reach out to you prior to this time frame.

Which Board are you interested in joining? *

Board of Directors

Advisory Board

About You

First Name *

Last Name *

Prefix *

Suffix

Ethnicity Identity/Race *

Black/African-American

Latinx

Native American / Alaska Native

Native Hawaiian / other Pacific Islander

Asian

White

Other

Prefer Not to Disclose

Gender *

Preferred Pronouns *

ex: they/them/their | he/him/his | she/her/hers

Birthday *

Email *

Cell Phone *

Home Address Line 1 *

Home Address Line 2

City *

Territory

State/Province *

County

Zip/Postal Code *

Country *

Instagram

ex: @elevatemedinc

ex: https://www.linkedin.com/company/elevatemedinc

Twitter

ex: @elevatemedinc

Comments / Questions

Public Information

If selected, the information in this section is used on elevatemed.org and referenced for ElevateMeD communications.

Biography

Headshot

please upload a high resolution photograph that may be used for marketing

WORK & AFFILIATIONS

Company Name *

Department

Job Title *

Affiliations & Other Titles

How did you hear about us?

If you selected other in the previous box, please provide details here.

Medical Education

If you are not. a physician, please scroll down to submit form.

Medical School

ex: University of Arizona College of Medicine - Phoenix

Residency Location (University/Institution)

ex: University of Arizona College of Medicine - Phoenix

Residency Program / Specialty

ex: Interventional Radiology (Integrated)

Residency Year Completed

ex: 2019

Physician Degree

M.D.

D.O.

Data Privacy & Consent

Yes, I would like to receive communications from ElevateMeD by SMS. I agree to receive promotional message sent via autodialer. This agreement isn't a requirement for any purchase or contribution. You may receive 4 msgs/mo. You may opt out at anytime. Reply STOP to end or HELP for help. Terms & Privacy Policy can be found at elevatemed.org/terms. Standard text message rates may apply.

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