2022-23 Member Registration - National Center for LMSA Leadership & Advancement

National Center for LMSA Leadership & Advancement

Member Registration for the 2022-23 Academic Year

Dear Current / Prospective Center Member,

Thank you for your interest in the Latino Medical Student Association (LMSA) and our inaugural National Center for LMSA Leadershiip & Advancement. This initiative aims to provide physicians, faculty members, staff, and healthcare professionals with resources for their continual development as leaders in medicine.

Specifically, the National Center will focus on providing LMSA advisors and their colleagues with the knowledge and skills to:

Successfully address the academic, personal, and professional needs and pursuits of diverse trainees, particularly those involved with LMSA;
Enhance discussion of issues in Hispanic & Latina/o/x health at advisors’ respective institutions; and
Understand how to utilize their LMSA-related work for promotion purposes.

We are proud to offer three National Center membership packages to academic medical centers - each with unique benefits - to help your institution meet your diversity and inclusion deliverables and achieve American Osteopathic Association (AOA), Liaison Committee on Medical Education (LCME), and Accreditation Council for Graduate Medical Education (ACGME) diversity standards. Benefits for each tier are depicted below and described further in this overview letter and on our webpage.

Premier ($8,000)	Elite ($5,000)	Enhanced ($3,000)
LMSA Chapter Advisor Orientation and Promising Practices Update (registration for 8 in person; 20 virtually)	LMSA Chapter Advisor Orientation and Promising Practices Update (registration for 4 in person; 8 virtually)	LMSA Chapter Advisor Orientation and Promising Practices Update (registration for 2 in person; 4 virtually)
LIDEReS : LHS+ Identity, Development, Empowerment, and Resources Seminar (registration for 3 in person; 6 virtually)	LIDEReS : LHS+ Identity, Development, Empowerment, and Resources Seminar (registration for 2 in person; 4 virutally)	LIDEReS : LHS+ Identity, Development, Empowerment, and Resources Seminar (registration for 1 in person; 2 virtually)
Hispanic Heritage Month Guest Speaker (1 hour presentation) + Community Conversation, and unlimited access to lectures	Hispanic Heritage Month Guest Speaker (1 hour presentation) and access to 4 lectures	Hispanic Heritage Month Guest Speaker (1 hour presentation) and access to 2 lectures
Featured as Premier Institutional Member on LMSA National Webpage with institutional logo and school link	Featured as Elite Institutional Member on LMSA National Webpage	Featured as Enhanced Institutional Member on LMSA National Webpage
E-Newsletter subscription and full page ad quarterly	E-Newsletter subscription and half page quarterly	E- Newsletter subscription
Academic Medicine Medical Spanish Fellow (1 person)

Please use this form to register for membership in the National Center for LMSA Leadership & Advancement for the 2022-23 academic year. Each membership term lasts THIRTEEN (13) months, extending from June 1, 2022 to June 30, 2023.

This form is enabled to securely accept payment via credit/debit card for any membership tier. You may also use this form and submit payment via check. For check payments, please select the the desired payment method on Page 2, address all checks to "The Latino Medical Student Association" and mail to the address below:

The Latino Medical Student Association
1 East Erie Street
Suite 525-4395
Chicago, IL 60611

A copy of the LMSA National W-9 Form is available here.

For any questions regarding this form or the National Center, please reach out to center@lmsa.net. We look forward to welcoming you as a member of the National Center this year.

National Center for LMSA Leadership & Advancement

New Member Registration Page 2 - Contact Information
Date

Month Day Year
Date
Institution Name *
e.g. University of Chicago Pritzker School of Medicine
Wherever "Contact Person" is referenced, please provide information for the form respondent: the individual completing this form.
Contact Person Name *

Prefix First Name Middle Name Last Name
Contact Person Email Address *
example@example.com
Contact Person Phone Number *
Please enter a valid phone number.
Position/Title of Contact Person *
Each institutional member of the National Center is asked to name one representative from that institution to be its primary point of contact. This representative is referred to as the National Center Leader for your institution.

This person is expected to attend monthly meetings with National Center leadership, provide feedback to LMSA on National Center activities, and respond to requests from LMSA regarding National Center initiatives.
Will the Contact Person above be the National Center Leader representing your institution? *

Yes No
Center Leader Name *

Prefix First Name Middle Name Last Name
Center Leader Email Address *
example@example.com
Center Leader Phone Number *
Please enter a valid phone number.
Position/Title of Center Leader *
On the next page, you will be asked to choose your institution's preferred membership tier and provide payment information.

National Center for LMSA Leadership & Advancement

New Member Registration Page 3 - Tier Selection
Membership Tier Selection *

Enhanced Tier - $3,000 Elite Tier - $5,000 Premier Tier - $8,000
If you have been provided with a promotional code or fee waiver, please enter the code below.
Please ensure that the promotional code entered is correct, as this form will not provide an error code for invalid entries.

National Center for LMSA Leadership & Advancement

New Member Registration Page 4 - Payment Information
Please select your desired form of payment below. (If a form of payment is not listed below, LMSA unfortunately cannot accept it.) *

Credit/debit card (subject to a 3% payment processing fee) Check
An invoice for 2022-23 National Center membership dues totaling ${membershipTier81} will be sent to the Payer specified below.
CC Fee
Amount Due (CC)
Amount Due (Other)
Payer Name

First Name Last Name
Payer Name Filled
Due

Month Day Year
Date
Billing Address (required for all orders) *

Street Address

Street Address Line 2

City State

Zip Code

The total for your order is shown below: *

USD This amount includes a 3% payment processing fee to help offset costs associated with accepting card payments.

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

By submitting this form, you confirm that you have:
- Provided information in this form that is truthful, accurate, and complete;
- Agreed to remit payment to LMSA in exchange for National Center membership benefits; and
- Committed your institution to participate in National Center programming during the 2022-23 academic year to the fullest extent possible.
Please hit "Submit" below to complete this registration form. If any questions or concerns arise, please contact center@lmsa.net.

NOTE: If the Submit button does not appear below, there is an error in your form responses above. Please ensure that the following questions are complete: method of payment, payer name, billing address.
Should be Empty: