LOUISIANA ACADEMY OF FAMILY PHYSICIANS
Family Doctor of the Day Session Dates: April 27- June 25, 2009
Volunteer today!!!!!
The Louisiana Academy of Family Physicians is asking its members to sign up to be "Family Doctor of the Day" at the capitol during the 2009 Legislative Session. This program will enable the LAFP to build an effective relationship with our senators and representatives; a relationship that should be maintained if our views and suggestions concerning health care are to be heard. We need volunteers for two hour shifts: Morning shift is 10:00 am to 12:00 pm, and Afternoon shift is 2:00 pm to 4:00 pm, Monday through Thursday as indicated below. You will be asked to perform non-invasive type procedures. Please complete and submit this application indicating your preferred date and time slot(s). Once you make your selection you will receive confirmation. A parking spot is available at the capitol for your convenience and you will be covered under the state malpractice insurance when providing your services.
Complete and submit the form below. You will be contacted by a representative from the LAFP office.
NAME:
HOME PHONE:
OFFICE PHONE:
FAX:
EMAIL:
HOME ADDRESS:
OFFICE ADDRESS:
PLEASE SELECT YOUR FIRST CHOICE
I WOULD LIKE TO VOLUNTEER FOR...
1 DAY
2 DAYS
3 DAYS
FIRST CHOICE:
JUNE 15 MORNING
JUNE 15 AFTERNOON
JUNE 16 MORNING
JUNE 16 AFTERNOON
JUNE 17 MORNING
JUNE 22 MORNING
JUNE 23 MORNING
JUNE 23 AFTERNOON
JUNE 25 MORNING
JUNE 25 AFTERNOON
If you would prefer to volunteer for an entire day, please note here:
PLEASE SELECT YOUR SECOND CHOICE
SECOND CHOICE:
JUNE 15 MORNING
JUNE 15 AFTERNOON
JUNE 16 MORNING
JUNE 16 AFTERNOON
JUNE 17 MORNING
JUNE 22 MORNING
JUNE 23 MORNING
JUNE 23 AFTERNOON
JUNE 25 MORNING
JUNE 25 AFTERNOON
If you would prefer to volunteer for an entire day, please note here:
PLEASE SELECT YOUR THIRD CHOICE
THIRD CHOICE:
JUNE 15 MORNING
JUNE 15 AFTERNOON
JUNE 16 MORNING
JUNE 16 AFTERNOON
JUNE 17 MORNING
JUNE 22 MORNING
JUNE 23 MORNING
JUNE 23 AFTERNOON
JUNE 25 MORNING
JUNE 25 AFTERNOON
If you would prefer to volunteer for an entire day, please note here:
Questions or Comments:
Indicates Response Required