Student Leadership Visit Request Form

Request a Leadership Visit

Inviting an ACOFP officer to speak at your chapter is an excellent way to promote family medicine. ACOFP will help select a speaker and cover their travel expenses. Submit your request at least 60 days before your event.

ACOFP officers are available to meet with student chapter leadership before or after programming. Please confirm the availability of the leadership team, Dean, and Family Medicine Department Chair before requesting dates. Please suggest up to three possible dates.

COM/Chapter^*

Contact Person/Title^*

Contact Person Cell^*

Contact Person Email Address*

Event Name

Name of Leader Requested^*

Requested Event Date #1

Requested Event Date #2

Requested Event Date #3

Program Location

Program Address

Program Time

Nearest Hotel Accommodations

Hotel Address

Hotel Website Link

Are CV and Photo of Visiting Officer Needed?

Please provide a draft itinerary, the names and titles of everyone the ACOFP officer will meet, and the requested speaking topics.

Type of Audience (students, other)

Number Expected

Please contact Annie DeVries at annied@acofp.org with questions. ACOFP will coordinate your request and respond within 10 days.