Leadership Team Member Application
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Academy Member Number
Which state do you reside in?
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
How long have you been a member of LAHIDAN?
Type a question
Chair-elect
Secretary
Treasurer
Communications Committee Chair
Diversity and Inclusion Liaison
Membership Committee Chair
Mentoring Coordinator
Newsletter Editor
Nominating Committee Chair-elect
Professional Development Committee Chair
Public Policy Coordinator
Social Media Coordinator
Website Coordinator
HOD Delegate
Most positions require about 2 hours/week of time commitment. Does your schedule permit to fulfill this position?
Yes
No
Have you or are you currently holding an executive committee (voting) position within Academy, DPG, MIG, etc?
Yes
No
Are you a member of other MIGs, DPGs, or Academy committees?
Yes
No
Please list your educational background, and/or career experiences and current area of practice:
Please list any previous leadership and volunteer roles or experiences:
Please list any special skills or training relevant to the position you are seeking, or that you feel could benefit LAHIDAN:
Submit
Should be Empty: