MDS Ambassador Program Application

Thank you for your interest in the International Parkinson and Movement Disorder Society's Ambassador Program. The Ambassador Program is intended to provide an excellent educational opportunity in Movement Disorders education to regions of the world not adequately served by the resources within that region. For more information on the policies, requirements, and structure of the Program, please see the Ambassador Program Policies and Procedures.

If you would like to invite an MDS Ambassador to present at a neurological meeting in your country, please complete and submit this application to the MDS International Secretariat. Up to two Ambassadors may be requested. Applications will be reviewed by the MDS Education Committee and selected based on the clarity and completeness of the program proposed, how well the program addresses the educational objectives indicated and how effectively the target audience need is explained.

Please complete the following:

* = Required

Applicant Contact Information

Applicant/Primary Organizer Name:*
Applicant Academic/Professional Affiliations:*
Hospital/Institution Name:*
Street Address:*

City:*
Postal Code:*
Country:*
Phone (include country code):*
Fax:
E-Mail:*
Statement of Educational Need
Please summarize the factors that qualify your educational activity for assistance through the Ambassador Program. See Ambassador Program Policies and Procedures for reference.
Proposed Ambassador Program Information
Official title of the meeting at which the Ambassador(s) will be speaking:*
Please provide the location of the meeting.*
Please provide the date(s) of the meeting.*
How often is the meeting held? (annually, monthly, etc):*
Will continuing education credit be offered?*
Yes    No
If yes, which type of credit? (CMD, CPD, nursing):
May MDS have access to the meeting participant mailing list or e-mail list?*
Yes    No
May MDS provide handouts/bag inserts for each meeting participant?*
Yes    No
Program Audience Information

Please identify the target audience of the Ambassador Program you are proposing:*
General Neurologists
Primary Care Physicians
Post-Doctoral Fellows
Physicians in Training
Researchers
Nurses/Health Professionals

Other   Please specify:

Language and Course Design
Language in which the program will be presented.*
Will translation of program materials be necessary?*
Yes       No
Will an interpreter be required?*
Yes       No
Anticipated number of program participants:*
Ambassador Information
If you would like to recommend an MDS Member from your region ideally suited to address the educational needs of your proposed program in the preferred language of the target audience, you may do so here. This recommendation will be evaluated among other potential regional candidates. As per the Ambassador Program Polices and Procedures, when more than one faculty is sponsored, not more than one half of sponsored faculty may come from beyond the region in which the program takes place. Suggested Ambassadors must represent different institutions. In an effort to maintain academic diversity in MDS educational programming, it is preferred that no academic or financial relationship exist between the suggested faculty and the host institution. However, it is understood that some exceptions may apply. Any pre-existing relationship should be disclosed below.
Suggested Ambassador 1:
Alternate Ambassador 1:
Proposed Lecture Topic:
Suggested Ambassador 2:
Alternate Ambassador 2:
Proposed Lecture Topic:
The suggested Ambassador(s) has (have) MDS Membership?
 Yes       No
Would the suggested Ambassador(s) provide the keynote/plenary lecture(s) for this meeting?
 Yes       No
Does your organization/institution have an academic/financial relationship with the suggested Ambassador(s)?
 Yes       No
If yes, please describe the relationship:
I am interested in applying to use the Parkinson and Movement Disorders curriculum as part of the Ambassador Program content
Program Evaluation
As with all of its educational activities, the International Parkinson and Movement Disorder Society will evaluate the effectiveness of this course through a compulsory Participant Evaluation Form. This form measures the knowledge of each participant, both prior to and after the course. Specifically, this evaluation form includes questions that gauge participants' intake of the identified learning objectives, assess general course content, and requests participants to rate each speaker on their presentation. Additionally, this evaluation measures whether the science and medical knowledge advanced by the activity will ultimately enhance the care of patients with Movement Disorders.

The following methods will be employed to measure the outcome(s) of the course:

Participant Evaluation Form
It is the responsibility of the host and MDS faculty to ensure that evaluation forms are completed by course attendees. Following the course, all completed evaluations are to be sent to the MDS International Secretariat for tabulation. In turn, the MDS International Secretariat will provide the evaluation results to the Host, MDS faculty members, as well as MDS and Regional Section Education Committees.

Optional:

  • Pre-test and Post-test. Please note that this method is ideal, however, it will require each faculty member to submit questions for the Pre- and Post- test.
  • Six-month follow-up questionnaire.
Application Templates
File Uploads
Please include the following with your application:
Your current CV (English):* 
Proposed Meeting Agenda including lecture topics, dates and times:*
Optional:
Draft of promotional material (Ex. Program Brochure) or other supporting materials:
MDS Ambassador Program Host Agreement
In person contact provides an invaluable opportunity to discuss collaboration on future Movement Disorder education. As a Host, the MDS Education Committee requests that you meet with the Ambassador(s) to discuss what MDS can do to support Movement Disorder education in the region.
I have read the MDS Ambassador Program Policies and Procedures and acknowledge the following:
* The Host must adhere to the Policies and Procedures that have been outlined with regard to the Ambassador Program that is being proposed. 
* The Host/Host organization is responsible for providing comfortable lodging, meals, local transportation, and ensuring the safety of the Ambassador(s) at the cost of the Host, while in the host country.
* MDS agrees to provide airfare for the Ambassador(s) according to the Travel Costs section of the Ambassador Program Policies and Procedures. 
* MDS agrees to provide honoraria for the Ambassador(s) in the amount of $1,000 USD for each Ambassador.
* The Host must ensure that a course summary, completed program evaluations and completed Regional Educational Needs Assessment Surveys (where applicable) are submitted to the MDS Secretariat within 60 days of the course date.

 

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