Member Community Online Application

AAPM&R physiatrist members of all different backgrounds and experiences have a new way to connect with each other—AAPM&R Physiatrist Member Communities! Member Communities are self-identified, organically established communities offering opportunities for physiatrist members to connect with each other, share experiences, and advance the future of the specialty together!
AAPM&R Physiatrist Member Communities can be:

Clinically focused (i.e., stroke, sports medicine, etc.)
Practice focused (i.e., inpatient rehabilitation, etc.)
Identity focused (i.e., women physiatrists, etc.)

The focus and goals of the community are up to you and your peers! You simply need to complete the application process, which requires your community goals and a minimum of 10 community members who are AAPM&R physiatrist members.

Please note, you may only be the chair of one Member Community at a time.

1. Please provide complete current contact information for who is submitting the application for a new Member Community.

First Name

Last Name

Title

Organization

City

State

Email Address

Work Phone Number

Mobile Phone

2. Are you a current member of the Academy?

3. What is the name of the proposed Member Community? For a list of current Member Communities, click here.

4. Please provide a 1-3 sentence summary of your proposed community so that other members can better understand your community. *This question is required.

5. What are the goals of the Member Community?

6. What type of Member Community is this?

7. In order for the Academy to best help the Physiatrist Member Community, an Interim Chair must be nominated. The Interim Chair will be the main contact for the Academy for questions regarding the application, member community recruitment, and the leadership election process. The term for the Interim Chair will be from the time the application is submitted until the inaugural election is completed. *This question is required.Please note, you may only be the chair of one Member Community at a time.

First Name

Last Name

Company Name

Email Address

Phone Number

Mobile Phone

8. Has the above named Interim Chair been contacted and approved this nomination? *This question is required.

9. A minimum of 10 Academy Physiatrist members are needed to apply for a Member Community. Please list their names below. Feel free to utilize the Member Directory to identify member names and email addresses.

Space Cell	Full Name	Company	Email	Cell Phone
Member 1	Member 1: Full Name	Member 1: Company	Member 1: Email	Member 1: Cell Phone
Member 2	Member 2: Full Name	Member 2: Company	Member 2: Email	Member 2: Cell Phone
Member 3	Member 3: Full Name	Member 3: Company	Member 3: Email	Member 3: Cell Phone
Member 4	Member 4: Full Name	Member 4: Company	Member 4: Email	Member 4: Cell Phone
Member 5	Member 5: Full Name	Member 5: Company	Member 5: Email	Member 5: Cell Phone
Member 6	Member 6: Full Name	Member 6: Company	Member 6: Email	Member 6: Cell Phone
Member 7	Member 7: Full Name	Member 7: Company	Member 7: Email	Member 7: Cell Phone
Member 8	Member 8: Full Name	Member 8: Company	Member 8: Email	Member 8: Cell Phone
Member 9	Member 9: Full Name	Member 9: Company	Member 9: Email	Member 9: Cell Phone
Member 10	Member 10: Full Name	Member 10: Company	Member 10: Email	Member 10: Cell Phone
Member 11	Member 11: Full Name	Member 11: Company	Member 11: Email	Member 11: Cell Phone
Member 12	Member 12: Full Name	Member 12: Company	Member 12: Email	Member 12: Cell Phone
Member 13	Member 13: Full Name	Member 13: Company	Member 13: Email	Member 13: Cell Phone
Member 14	Member 14: Full Name	Member 14: Company	Member 14: Email	Member 14: Cell Phone
Member 15	Member 15: Full Name	Member 15: Company	Member 15: Email	Member 15: Cell Phone

10. I have contacted each member on this application to ensure that he/she is a member of AAPM&R and would like to join this member community. *This question is required.

Member Community Online Application

Physiatrist Member Community Online Application