PAS Workshop Committee Nomination Form

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.

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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

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8. Confirmation Will Attend PAS 2023-2025 Meetings*

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9. Diversity, Equity & Inclusion- Gender*

Please select all that apply.

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10. Diversity, Equity & Inclusion- Race*

Please select all that apply.

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11. Diversity, Equity & Inclusion- Ethnicity*

Please select all that apply

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12. Upload CV with Pertinent Activities Highlighted*

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Date Application Submitted*

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