2013 Delegate Registration

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Please complete the form below to register your chapter's delegates for AMSA's 2013 House of Delegates. Please note that the HOD is "going green" this year. All delegates are asked to be sure to bring a laptop to Convention for use during the HOD. At Convention, each HOD delegate will be given an AMSA jumpdrive with all HOD documents preloaded.

Questions? Email Nida Degesys at vpia@amsa.org.

Medical School/Chapter: *

Name: *

Email address: *

Chapter Role: *

Chapter President

Chapter Vice President

Chapter Committee Chair

Chapter Member

National Leader

Other:

If you are not your chapter's President, please list his/her name:

If you are not your chapter's president, please list his or her email address.

Delegate 1: Name *

Please re-enter even if same as above.

Delegate 1: Email address *

Please re-enter even if same as above.

Delegate 1: Phone number *

Delegate 2: Name

Delegate 2: Email address

Delegate 2: Phone number

Delegate 3: Name

Delegate 3: Email address

Delegate 3: Phone number

Delegate 4: Name

Delegate 4: Email address

Delegate 4: Phone number

Please indicate your agreement with the statement below. *

By submitting this form, I declare the following delegates are AMSA medical members and the duly elected (or appointed) delegates of the designated American Medical Student Association Chapter. These delegates are active members in good standing of the Association and are authorized to participate in deliberations of the House of Delegates.

Required

Please indicate your agreement with the statement below. *

By submitting this form, I acknowledge that all delegates are expected to bring a laptop computer for use in the HOD. AMSA flashdrives will be given to all delegates with all HOD materials preloaded.

Required

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This form was created inside of American Medical Student Association.