Academy Ambassador Application 2025 - Mississippi Academy of Family Physicians

Name*

First Last

Medical School*

Year in Medical School (as of Fall 2025)*

Anticipated Graduation Date*

Mobile Phone*

Email*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Personal

Gender*

Female
Male

Hometown (city and state where you grew up)*

T-shirt Size*

Are you a member of your medical school's FMIG/ACOFP chapter?

Yes
No

On a scale of 1-10 (with 10 being the highest), how interested are you in pursuing family medicine?

Social Media Handles

Simply so we can tag you when we post.

Instagram Handle*

Facebook Name*

Twitter Handle

Professional References

Reference #1 Name*

First Last

Reference #1s Title and Organization/Business Name*

Reference #1 – How does this person know you?*

(employer, advisor, etc.)

Reference #1 Phone*

Reference #1 Email*

Reference #2 Name*

First Last

Reference #2 Title and Organization/Business Name*

Reference #2 – How does this person know you?*

(employer, advisor, etc.)

Reference #2 Email*

Reference #2 Phone*

Additional Questions

Please explain why you would like to work during the MAFP Annual Meeting and what you hope to gain from this experience.*

Please describe your personal strengths and any previous experiences (leadership, job, educational or service experiences) which demonstrate your ability to be a valuable ambassador.*

Application Deadline

The deadline to apply to be an Academy Ambassador is May 1 of each year.

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Academy Ambassador Application (2025 Annual Conference)

Personal

Social Media Handles

Professional References

Additional Questions

Application Deadline