2021 Family Medicine Educator of the Year formPlease enable JavaScript in your browser to complete this form.Nominee's Information (click the button at the bottom to submit!)Physician's Name *FirstLastPhysician's home address (submit as much as you know)Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhysician's business address (submit as much as you know)Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Is this the phone number for the nominee's ... *homecellofficeFax (if applicable)Email *Is the nominee a WAFP member? *YesNoYour InformationYour Name *FirstLastYour Email *Your PhoneAdditional InformationThe Family Medicine Educator of the Year Award recognizes Academy members for excellence in teaching, development of innovative teaching models, or implementation of outstanding educational programs. One award is presented each year to a full-time, part-time or volunteer faculty member. The WAFP Family Medicine Educator of the Year is recognized at the Annual Banquet and Foundation Auction (scheduled for May 2021), a celebratory plaque and a cash prize of $500. The award includes overnight accommodations and two banquet tickets (if the event is held in person).Washington Academy of Family Physicians 1239 120th Ave. NE, Suite G Bellevue, WA 98005 info@wafp.net Fax: 425-747-3109 Nominations must be received by Jan. 29, 2021 Nomination Requirements Completed nomination form Current curriculum vitae Three to five letters of recommendation, of which at least two must be from current for former students/residents who have been taught by the nominee Selection Criteria Nominees’ recognition for exemplary teaching skills and outstanding progression of abilities over several years by medical students, residents or peers; or Nominees’ development and implementation of innovative curriculum, teaching model(s) or program(s) in a variety of educational spheres; and Nominees’ membership in WAFP (nominees must be members to be considered). Is your PDF (including letters of recommendation and nominee's CV) ready to upload?YesNoLet's do it! Use the field below to upload your documentation: Click or drag a file to this area to upload. This is the Button to Click to Submit Contact Information!
