American Academy of Family Physicians

2011 FMIG Survey

Medical School Information
Name of Medical School
Family Medicine Interest Group name
FMIG web site URL
Month that new student leaders are selected/elected
Is the FMIG located at:
Main campus
Branch campus; name:
Other:

FMIG Primary Faculty Advisor-Physician

Name:
Title:
Mailing address:
City:
State:
Zip:
E-mail:
Number of years serving as advisor:
May we register your primary faculty advisor for the FMIG Faculty Advisor Listserv hosted by the AAFP FMIG Network?
Yes (be sure to include e-mail address above)
No

FMIG Faculty Advisor or Support Staff - Non-Physician

Name:
Title:
Mailing address:
City:
State:
Zip:
E-mail Address
Number of years serving as advisor

May we register your your non-physican faculty advisor or support staff for the FMIG Faculty Advisor Listserv hosted by the AAFP FMIG Network?
Yes (be sure to include email address above)
No

FMIG Primary Student Leader Contact

Name:
Title:
Mailing address:
City:
State:
Zip:
E-mail:
Is the primary student leader contact an AAFP student member?
Yes
No

Class year of primary student leader

M1
M2
M3
M4

May we register your primary student leader for the FMIG Student Leader Listserv hosted by the AAFP FMIG Network?

Yes (be sure to include email address above)
No

FMIG Alternative Student Leader Contact

Name:
Title:
Mailing address:
City:
State:
Zip:
E-mail:
Class year of alternative student leader
M1
M2
M3
M4

May we register your alternative student leader for the FMIG Student Leader Listserv hosted by the AAFP FMIG Network?

Yes (be sure to include email address above)
No

AAFP Student Membership Coordinator

Name:
Title:
Mailing address:
City:
State:
Zip:
E-mail:

Class year of AAFP student membership coordinator
M1
M2
M3
M4

Is the student membership coordinator a member of the FMIG?

Yes
No