Medical School:

Sponsor/Faculty Name:

Business Address:

Phone Numbers:

E-mail Address:

Primary Subspecialty: Academic Appointment:

Resident Name:

Business Address:

Phone Numbers:

E-mail Address: Expected Graduation:

President Name:

Home Address:

Contact Phone Number: E-mail Address:

Medical School Year:

Vice President Name:

Home Address:

Contact Phone Number: E-mail Address:

Medical School Year:

Secretary Name:

Home Address:

Contact Phone Number: E-mail Address:

Medical School Year:

Please provide any other student officer demographic information, including their role/title, on a separate sheet.

Please provide a brief description of the organization of your medical student chapter and include:

1. How will you format your chapter meetings? How frequently will you meet? What will be the structure of your meetings? How will you foster interest in membership of the chapter?
2. Are there projects (research, institutional, service) that you would like to accomplish?
3. How will you use the chapter to integrate with the department of neurosurgery at your institution?

The following documents should be e-mailed to memberservices@aans.org:

• A letter/statement of support from the dean of student affairs and neurosurgery program chair (If this medical school does not have a neurosurgical program, a letter of support from any AANS member neurosurgeon will be required.)
• Draft of chapter charter
• A list of the names, address, e-mail address, and anticipated date of graduation for all chapter members you wish to enroll as AANS medical student members for the duration of their medical school career

By signing this application, the Sponsor agrees to:

• Maintain a copy of the Chapter Charter on file for future review
• Abide by the rules and regulations governing medical student organizations germane to your medical school
• Maintain active membership in the American Association of Neurological Surgeons
• Maintain an AANS medical student chapter in good standing that will abide by the rules and regulations applicable to all AANS members and organizations and will specifically –
• Maintain a leadership structure delineated by the chapter charter
• Hold annual elections or provide for an orderly succession to insure that all leadership positions are filled
• Submit an electronic annual report detailing the membership, fundraising, research, educational, and social activities of the AANS medical student charter
• Alert the AANS through the Medical Student Subcommittee of the Young Neurosurgeons Committee of all changes or alterations of the above agreement

        

Sponsor/Faculty Mentor Signature Name (please print)

There is a $50.00 US submission fee that is to accompany this AANS medical student chapter application.

Name on Card:

Credit Card Number:

Expiration Date:       Card Security/Verification Code:

        

Card Holder's Signature Date