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Ambassador Program

MDS Ambassador Program Application

Thank you for your interest in The 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.

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. 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 fields are marked with an *

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:
Email: *

Proposed Ambassador Information Official title of the meeting: *
Please provide the location of the meeting: *
Please provide the dates 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? (CME, CPD, nursing) *

May MDS have one-time access to a post meeting mailing or e-mail list? * Yes    No

May MDS provide handouts/bag inserts for each meeting participant? * Yes    No

File Uploads

Please include the following with your application:

Your current CV:
Draft of meeting agenda:
Draft of promotional material (such as a brochure):

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/Ancillary Health Care Workers    Other:

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 you like to recommend an MDS member 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 candidates.

Suggested Ambassador 1:
Suggested Ambassador 2:
Suggested Ambassador 3:
Suggested Ambassador 4:
Suggested Ambassador 5:
Suggested Ambassador 6:

Would the Ambassador be the keynote speaker for this meeting? Yes No

I have read the guidelines regarding The Movement Disorder Society's Ambassador Program, and acknowledge the following:

* The host is responsible for providing comfortable lodging accommodations, meals, local transportation and ensuring the safety of the Ambassador(s) at the cost of the Host, while in the host country.

* MDS will provide airfare and honorarium for the Ambassador(s) in support of the program.

* Following the event, the Host must ensure that program evaluations are completed by participants, and submitted to the MDS International Secretariat.

* I agree to adhere to the policies/guidelines that have been outlined with regards to the Visiting Professor Program I am proposing.