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American Academy of Dermatology2009 Leadership Forum ...

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  • 1. American Academy of Dermatology 2009 Leadership Forum & Academic Dermatology Leadership Program Combined Application ♦ ♦ ♦ ♦ ♦ April 17-19, 2009 Chicago, IL Please indicate which program(s) you are applying for (check both if you wish to be considered for the Leadership Forum even if not selected for the Academic Program): 2009 Leadership Forum (Please complete this page and Sections A-D) A highly interactive weekend conference that will provide an opportunity to advance your leadership and communication skills while networking with colleagues and Academy leaders. 2009 Academic Dermatology Leadership Program (Please complete this page and Sections A-E) The Academic Dermatology Leadership Program is a year-long program specifically designed for academic dermatologists who are in the early stages of their careers. The program focuses on providing management and leadership training for the academic career path and includes the 2009 Leadership Forum and onsite leadership training sessions at the AAD Annual and Summer Meetings, commitment to complete online course work, and participation in a mentoring program. NAME ADDRESS CITY STATE ZIP CODE HOME TELEPHONE BUSINESS TELEPHONE FAX EMAIL ADDRESS PAGER / CELL PHONE MEMBER NUMBER YEAR OF GRADUATION FROM DERMATOLOGY RESIDENCY Indicate below the percentage of your professional time spent in each of the following: _____% Private (Solo) Practice _____% Dermatology Group Practice _____% Multi-Specialty Group Practice _____% Fellowship _____% Academic _____% Other
  • 2. American Academy of Dermatology and AAD Association 2007 Leadership Forum & Academic “Masters” Program Combined Application Page 2 (If any time is spent in academics, please fill in the information below with regard to your academic appointment.) ACADEMIC TITLE ACADEMIC PROGRAM
  • 3. SECTION A Please list up to five leadership positions held (e.g. professional, academic, community, medical societies, etc.). Note that extensive leadership experience is NOT a requirement. 1. 2. 3. 4. 5. Briefly describe how you have utilized your current leadership skills to make a difference in one of the leadership positions listed above. (100 words or less)
  • 4. 2009 Leadership Forum & Academic Dermatology Leadership Program Application Page 4 SECTION B Please list your top three leadership… Strengths 1. 2. 3. Weaknesses 1. 2. 3. SECTION C IMPORTANT! Briefly describe what you hope to gain from the 2009 Leadership Forum and/or Academic Dermatology Leadership Program, and how you hope to apply your developing leadership skills in the future. (150 words or less)
  • 5. 2009 Leadership Forum & Academic Dermatology Leadership Program Application Page 5 SECTION D Other professional organizations in which you currently hold a membership? (Please check all that apply.) American College of Mohs Surgery American Society for Mohs Surgery American Society for Dermatologic Surgery American Society of Dermatopathology Association of Professors of Dermatology Medical Dermatology Society Society for Investigative Dermatology Society for Pediatric Dermatology Women’s Dermatologic Society Local or State Dermatology Society State Medical Society American Medical Association Other Note: Applicants applying solely for the 2009 Leadership Forum, please see final instructions on page 6. Applicants applying for the 2009 Academic Dermatology Leadership Program must also complete Section E (page 5) of this application and then follow the final instructions on page 6.
  • 6. 2009 Leadership Forum & Academic Dermatology Leadership Program Application Page 6 SECTION E ACADEMIC DERMATOLOGY LEADERSHIP PROGRAM APPLICANTS ONLY Academic dermatologists (who spend at least 75% of their professional time in academics) are eligible for the 2009 Academic Dermatology Leadership Program. This is an intensive program, which requires a full-year commitment of approximately 5-8 hours per month in addition to the three on-site sessions. Please carefully read the program description included with this application and make sure you are able to make the commitment before you apply. Please describe, in 125 words or less, your current interest and involvement in academic dermatology, your future career aspirations, and the challenges you have faced and anticipate facing in this field. Please describe the skills or knowledge you feel would be useful to you in addressing the challenges described above and advancing your involvement in academic dermatology.
  • 7. 2009 Leadership Forum & Academic Dermatology Leadership Program Application Page 7 ATTENTION: All applicants must submit: 1. Completed Application 2. One letter of recommendation from an individual who can speak to your professional commitment 3. Executive CV (Limit of no more than three pages) Email your completed application and supporting documents to Linda Ayers at layers@aad.org by Wednesday, October 15, 2008. If you prefer, you may fax your application to (847) 240-1920. All applicants will be notified of their status December 15, 2008. If you have any questions, please contact Linda Ayers (847-240-1251 or layers@aad.org).

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