PAS Workshop Committee Nomination Form

Please provide the following information by June 24, 2022.

1. Nominee Name

2. Nominee Email Address

3. Domain(s) of Expertise

Please select all that apply.

4. Description of Expertise in Domain(s) selected

5. Description of Expertise as Medical Educator

6. Description of Prior Involvement

Please describe your prior involvement with PAS Meeting, PAS workshops and/or other medical or academic conferences in pediatrics.

7. Confirmation of Member in Good Standing

Please select all that apply

8. Confirmation Will Attend PAS 2023-2025 Meetings

9. Diversity, Equity & Inclusion- Gender

Please select all that apply.

10. Diversity, Equity & Inclusion- Race

Please select all that apply.

11. Diversity, Equity & Inclusion- Ethnicity

Please select all that apply

12. Upload CV with Pertinent Activities Highlighted

Please upload your CV

Drop your files here

Date Application Submitted

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