Join a Chapter Committee! | Maryland Chapter of ACEP

2025 Chapter Committee Submission Form

This form should be used if you are interested in becoming a member of a Maryland ACEP Chapter Committee. The Committees are Education, EMS, Membership, Pediatric EM, EMPACt (PAC), Practice Management, Legislative/Public Policy, and Nominations Committees. Read more about each committee (https://www.mdacep.org/committees/)

Personal Information

Name(Required)

First Middle Last Credentials

Email(Required)

Enter Email Confirm Email

Cell Phone(Required)

This number will not be shared with anyone outside of the Maryland ACEP Chapter Board or Chapter Executive Director.

Preferred Contact Method(Required)

Which Chapter Committee are you interested in?(Required)

Multiple can be chosen.

Why does this/do these Chapter Committees interest you?(Required)

Hospital Affiliation

Name of Hospital(Required)

Address of Hospital(Required)

City State / Province / Region

What is your current role?(Required)

Headshot(Required)

Please upload a headshot

Accepted file types: jpg, jpeg, gif, Max. file size: 50 MB.

Curriculum Vitae(Required)

Accepted file types: pdf, doc, docx, Max. file size: 50 MB.

Questions, Comments, and Concerns

Please use this section to provide any additional information relevant to your interest in a Chapter Committee (if necessary).