EMIG Symposium Sponsorship Application

Name of Medical School:
Address:
Address 2:
City:
State:
Zip:
Website Address:
EMIG Contact Name:
Email Address:
Phone Number:
Other Symposium Volunteers:
Amount Requested ($1000 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
 
We will allow an AAEM and/or AAEM/RSA representative to speak during the symposium. We understand that we will coordinate this effort with the AAEM/RSA president and/or the AAEM/RSA medical student council president once the grant has been approved.
 
If yes, what is the proposed time slot?
 
We agree to charge AAEM/RSA student members a fee of $20; all nonmembers and AAEM/RSA Student Free members a fee of $60, and all walk in registrants a fee of $70. We understand that those registering at the $60 or $70 rate will automatically become an AAEM/RSA student member, pending eligibility.

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!