HOD Committee Volunteer Form

NOVEMBER 2024 HOD COMMITTEE VOLUNTEER FORM
This form is to be completed by volunteers for reference committees (other than F), the Rules & Credentials Committee, and tellers for HOD meetings. Please indicate all committee/s on which you would be interested in serving. You may select multiple individual committees or select “ANY” if you are open to serving where needed.

Preference will be given to those who have not recently served; however, all interested are encouraged to apply. Those who currently serve on AMA councils will not be considered for service to allow for leadership opportunities for others.

Reference committees will meet virtually on Saturday, November 2, 2024, to develop their Preliminary Reference Committee Reports based on testimony received online. We ask that all who are interested in serving on reference committees hold that weekend open to accommodate these meetings.
Are you available to meet virtually on Saturday, November 2, 2024, if selected to serve on a reference committee?*

YesNo
Would you like to volunteer to serve as Chair of a reference committee?

Yes
Name*

First NameLast Name
Email*
example@example.com
State*
Mobile Number*

Area CodePhone Number
Specialty*
Please select one*

DelegateAlternate DelegateRegional Medical Student DelegateRegional Medical Student Alternate DelegateSectional Resident DelegateSectional Resident Alternate Delegate
Name of the society or section you represent in the House of Delegates*
Are you currently serving on an AMA Council?

YesNo
Which AMA Council are you serving on?*
HOD Committees*

AnyK - Advocacy related to science and public healthCB - Admendments to Constitution and BylawsRC - Rules and Credentials CommitteeB - Legislative advocacyC - Advocacy related to medical educationT - TellerJ- Advocacy related to medical service, medical practice, insurance, and related topics
Previous AMA HOD Committee Service*
Please list the last three years of COMMITTEE service, including service at the state, local, specialty, and/or section level, and indicate if you chaired the committee.
Statement of Interest*
Not to exceed 150 words.
Headshot for Pictorial Directory (optional)

Browse Files
Upload a headshot (.png, .jpg, or .jpeg) which will be added to the AMA's Pictorial Directory Cancelof
If you have questions or require additional information please contact Patti Wargo, Office of House of Delegates Affairs at patti.wargo@ama-assn.org or 312-464-4463.
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NOVEMBER 2024 HOD COMMITTEE VOLUNTEER FORM