EMIG Symposium Sponsorship Application

Name of Medical School:
Address:

City:
State:
Zip:
Website Address:
EMIG Contact Name:
Email Address:
Phone Number:
Other Symposium Volunteers:
Amount Requested ($500 is maximum): $
If funding is approved, what will the grant be used for?

Proposed Date for Symposium:
Alternate Date for Symposium:

Will AAEM/RSA be allowed to have a free table or booth to display materials and sign up student members?

Yes No

Will a representative of AAEM/RSA be provided a slot to speak during the student symposium?

Yes No
If yes, what is the proposed time slot?

Please Attach Tentative Program Agenda, List of Proposed Speakers and Draft Budget.

Attach Agenda here:
Attach List of Proposed Speakers here:
Attach Draft Budget here:

Please note that the AAEM/RSA board of directors will need to approve the application, so please allow ample time for the approval process.

Thank you!

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