LIDEReS 2023 Participant Registration

LIDEReS 2023 Participant Registration

National Center for LMSA Leadership & Advancement

Dear LIDEReS Participant,

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

The first Center event of the new year is our LIDEReS program: The Latina/o/x Identity, Development, Empowerment, and Resources Seminar. This two-day seminar brings together faculty (including residents with signed contracts for faculty positions and fellows) and physician advisors from across the United States and provides participants with inspirational and practical guidance and tools for pursuing career advancement in academic medicine. The seminar will help participants develop key professional competencies that build self-efficacy, communication skills, and leadership while expanding their network of colleagues, role models, advisors, and champions.

This year's LIDEReS session will take place virtually on February 17-18, 2023 (Friday- Saturday). Events on each day will occur from 10:00 am to 4:00 pm EST. Continuing Medical Education (CME) credits will be provided.

Please use this form to register for the event (or to submit registration information on behalf of another individual). This form may be used to register multiple participants at once. To do so, please enter one participant's information at the bottom of Page 1, click SAVE, and repeat for each individual to be registered.

Institutional members of the National Center for LMSA Leadership & Advancement may claim their complimentary registrations using this form. At the payment stage, please enter the promotional code provided to your institution. Individuals who are not affiliated with an institutional member of the National Center are also welcome to participate in this event, and are subject to the registration fees below:

Registration Period	Dates	Registration Fee
Early	December 1, 2022 - January 9, 2023	$250
Regular	January 10, 2023 - February 15, 2023	$300
Late	February 12, 2023 - February 16, 2023	$350

This form is able to securely collect payment information using credit/debit card.

Lastly, after completing this form, registrants will receive a Zoom meeting link and a pre-event survey to complete as soon as possible. Please look out for email communications from center@lmsa.net.

For any questions regarding this form, the LIDEReS seminar, or the National Center, please reach out to center@lmsa.net. We look forward to having you at this year's event.

Tentative Agenda:

https://docs.google.com/document/d/1FaGXHhyo6xv0SchX6Io3F2sNUmQ1TTPeYbs1yGb3FLU/edit?usp=sharing
Date

MonthDayYear
Date
Cost Per Registrant
Are you registering a speaker or a moderator (yourself or someone else)?*

YesNo
You may not use this form to register a speaker or moderator. Please use the LIDEReS speaker/moderator registration form here to do so.
Please provide information for the form respondent - the individual completing this form - wherever it says "Contact Person."
Contact Person Name*

First NameLast Name
Contact Person Email Address*
example@example.com
Contact Person Phone Number*
Please enter a valid phone number.
Institution Name*
Is your institution a member of the National Center for LMSA Leadership & Advancement?*

YesNo
Please indicate the tier of your institution's membership with the National Center.*

EnhancedElitePremier
Would you like to speak with someone regarding becoming an institutional member of the National Center for LMSA Leadership & Advancement?

YesNo
How many individuals would you like to register for LIDERES 2023?*
Minimum 1
Please enter information for each participant below. Make sure to click "SAVE" below after entering each registrant's information. You may make multiple entries using this field. (Please complete this question even if you are registering yourself and have provided your information above.)*
The number of participants you have entered above does not equal the number of individuals you indicated you would like to register. This form cannot be submitted unless names and email addresses have been provided for each desired registrant. Please correct this discrepancy before proceeding. Thank you.
Registrant Number
The total for your order is below (in $USD). Discounts for National Center members may be claimed on the next page.

LMSA LIDERES 2023 Registration - Page 2

Benefit Redemption for National Center Members
On Page 1, you indicated that you are not affiliated with an institutional member of the National Center for LMSA Leadership & Advancement. If this is incorrect, please modify your response on the previous page. If this is correct, you may proceed to the next page.
FOR LMSA STAFF USE ONLY: ADJUSTMENTS
On Page 1, you indicated that you are affiliated with an institutional member of the National Center for LMSA Leadership & Advancement. If this is incorrect, please modify your response on the previous page. If this is correct, please respond to the question(s) below.
Would you like to redeem the complimentary LIDEReS registrations attributed to your institution as a National Center member?*

YesNo
As an Enhanced institutional member, you may redeem up to 2 LIDEReS registrations total. Registrations above this number will be charged.
As an Elite institutional member, you may redeem up to 4 LIDEReS registrations total. Registrations above this number will be charged.
As a Premier institutional member, you may redeem up to 6 LIDEReS registrations total. Registrations above this number will be charged.
How many complimentary registrations would you like to redeem?
Please enter the member promotional code provided to your institution.
An incorrect code with not trigger the appropriate discount. Please ensure that the code written above is correct before submitting this form.
Member Discount
Speaker Discount
Total Discount
Price

LMSA LIDERES 2023 Registration - Page 3

Terms & Conditions and Payment Information
Thank you for redeeming your compiimentary LIDEReS registrations as a benefit of National Center membership. There is no cost associated with this order. Please review our Event Terms & Conditions below and press "Submit" to submit this registration form.

Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
By submitting this form, you confirm that you have:
- Read, understood, and agreed to the LMSA National Event Terms & Conditions;
- Provided information in this form that is truthful, accurate, and complete;
- Agreed to attend this program to the best of your ability; and
- Consented to remit payment to LMSA for event registration equal to the amount shown above (if the price of this order is above $0).
Please hit "Submit" below to complete this registration form. Form submissions will be reviewed for completeness and approved or rejected within 72 hours. For any questions, please contact center@lmsa.net.

NOTE: If the Submit button does not appear below, there is an error in your form responses on Page 1. Please ensure that you provide information on all participants you wish to register, including yourself, if applicable. The number of participant emails must equal the number of desired registrants. Moreover, you cannot use this form to register a speaker or moderator. Please use the LIDEReS speaker/moderator registration form here to do so.
Should be Empty:

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

LIDEReS 2023 Participant Registration

LMSA LIDERES 2023 Registration - Page 2

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