CFS Application Form

Name:*

First Last

Preferred first name/nickname (as you would like it on your badge should you be accepted to the program):

Degree(s) earned (e.g., MD, MPH):*

Institutional/work email:*

Personal email:*

Preferred email for program communications:*

Personal telephone:*

Institution Address

Residency program/medical school name:*

Specialty (i.e., internal medicine, family medicine, other - please explain):*

Institution address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Medical school affiliation, if any:*

Write N/A if there is none.

Hospital affiliation, if any:*

Write N/A if there is none.

Name of person who will write your letter of support (i.e, your Division Chief/Program Director/Department Chair):*

Email of person who will write your letter of support:*

Current faculty position:*

Current academic rank*

Instructor
Assistant Professor
Associate Professor
Professor
Other
None

If "Other"- Please Specify

Number of years as faculty at your institution:*

Please enter a number. Junior faculty should have at least one and less than ten years of experience as faculty.

Percentage of time teaching:*

Please enter a number from 0 to 100.

Please approximate the percentage of time you spend teaching. Enter a number from 0 to 100; do not use a percent sign.

Mailing Address

Same as institution mailing address above?*

Yes
No

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Other Information

Gender identity:*

If you selected "Prefer to self describe," please specify here:

Pronouns

If you selected "Prefer to self describe," please specify here:

Race/ethnicity :*

Black or African American
American Indian or Alaska Native
Asian
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other

Select all that apply.

Please describe "other":

Have you ever visited the following in a professional context? (Check all that apply.)

A mutual help or 12-step program (e.g., AA, NA, Learn to Cope)
A substance use treatment facility only (e.g., detox, methadone maintenance)
A harm reduction program (e.g., syringe service, naloxone distribution)

Preferred T-shirt size (should you be accepted to the program):*

Please provide a personal statement of 500 words or less that includes your motivation for participating in the program and your plans for creating an addiction medicine curriculum. Copy-paste this into the box below.*

Please upload a letter of support from your Division Chief/Program Director/Department Chair that emphasizes how the institution will facilitate dissemination and sustainability of an addiction medicine curriculum.

Accepted file types: doc, docx, pdf, Max. file size: 100 MB.

If you don't have this ready at the time of application submission please have it emailed to Jules Canfield at jules.canfield@bmc.org prior to the application deadline.

Curriculum Vitae

Please upload your curriculum vitae (CV) as a PDF here.*

Accepted file types: doc, pdf, docx, Max. file size: 100 MB.

How did you hear about the CARE Faculty Scholars Program?*

Previous program attendee
Faculty at my institution
Brochure or postcard advertising the program
Internet search
Email directly from the program
Other (describe below)

Please describe "other":

Please specify:

5th Annual CARE Faculty Scholars (CFS) Program Application

Institution Address

Mailing Address

Other Information

Curriculum Vitae