Chris MahaffeyLeadership DevelopmentProgramApplication

Demographic Information

Name*

Primary Address*

Email*

Cell*

ACFAS Member ID#*

Annual Scientific Conferences Attended*

Please check all that apply.

Educational Offerings

What additional ACFAS educational offerings have you taken advantage of?

Educational Offerings-Please check all that apply.

ACFAS Arthroscopy of the Foot and Ankle Workshop

ACFAS Advanced Surgical Skills Workshop (Surgical Management of the Active Patient, Advanced Arthroscopy, Total Ankle, etc.)

ACFAS Region Course Offering

On-the-Road, Coming to You, etc.

ACFAS Webinar or Virtual Conference

ACFAS On-Demand Module

Other ACFAS offerings not listed above?

Other committees/roles not listed above?

If yes, what committee(s)/roles?

Have you completed Level 1- Leadership Development*

Have you completed/are you completing Level 1 of the Leadership Development Program? Level 1 must be completed by April 3 to be considered for the 2023-24 Level 2 program.

Select or enter value

Applicant Recommendations

Applicant Recommendations*

Please provide the name and email of one leader/mentor/educator that will be able to complete a short survey on your behalf stating why you will be a good candidate for this workshop. A survey link will be sent out directly to them.

Applicant Narratives Instructions

Your answers will be used to support why you should be considered for the program. Be sure you clearly outline your leadership skills through your activities with ACFAS, other organizations and your local community. Reviewers will be rating you on your responses to the questions asked and will rely heavily on your answers and your letters of recommendation.

Narrative- Areas of Interest*

What areas of interest or specific goals and objectives do you want to accomplish, and how would completing the College’s Leadership Development Program help you achieve these objectives? (500 words or less)

Narrative- Professional Journey*

What role has ACFAS played, or will play, in your professional journey? (500 words or less)

Narrative- Future of the Profession*

What is the greatest challenge facing the profession? If you were a member of the ACFAS leadership team, how would we work to address it? (500 words or less)

Additional Materials*

Please upload the following materials:

Updated CV
Headshot

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Send me a copy of my responses