2025 HOD Committee Volunteer Form

JUNE 2025 HOD COMMITTEE VOLUNTEER FORM
This form is to be completed by volunteers for reference committees (other than F), the Rules & Credentials Committee, and assistant tellers for A-25. Please indicate all positions which you would be interested in serving. You may make multiple individual selections or choose “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.

All reference committees will meet virtually between May 24 and 29, 2025 for their preliminary executive session and report reviews. Reference committee staff, in conjunction with the chair, will schedule the dates/times of these meetings but we ask that all who are interested in serving on reference committees have availability between May 24-29, 2025.
Are you available to meet twice between May 24-29, 2025, if selected to serve on a reference committee?*

YesNo
Would you like to Chair a committee? (previous service on a committee required)

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*

E&B - Ethics and BylawsA - Medical ServiceB - LegislationC- Medical EducationD - Public HealthE - Science and TechnologyG - Medical PracticeRC - Rules and Credentials CommitteeT - Assistant TellerAny
Previous AMA HOD Committee Service*
Please list previous COMMITTEE experience, including service at the state, local, specialty, and/or section level, and indicate if you chaired a 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.
Should be Empty:

JUNE 2025 HOD COMMITTEE VOLUNTEER FORM