SMSNA RIG Application Form

Regional Interest Group (RIG) Application Form
Regional Interest Groups (RIGs) have been established to make connections between individuals with a similar interest in a designated geographical area. To start a RIG in your geographical area, please complete the below information.
Region of your proposed interest group*
City, State
This RIG is to be:*

Restricted to institutionRestricted to cityRestricted to stateNo restrictionsOther
Please identify the RIG leads:
Medical Student Champion:*

First NameLast Name
Designation:*
(MD, DO, PhD, etc.)
Email:*
example@example.com
Resident Champion:*

First NameLast Name
Designation:*
(MD, DO, PhD, etc.)
Email:*
example@example.com
Faculty Anchor:*

First NameLast Name
Designation:*
(MD, DO, PhD, etc.)
Email:*
example@example.com
What are the objective(s) and goal(s) for your RIG:*

EducationResearchPublic OutreachOther
Please explain the need for your proposed RIG:*
Every RIG will have an initial meeting over Zoom to discuss the overall goal of the RIG, proposed activity/event and the best method(s) of presenting the activity/event. Please let us know when you would like to schedule your initial meeting (after approval). Please indictate 3 different dates/times you would be available for this initial meeting.
1st Choice*
2nd Choice*
3rd Choice*
What timezone are you in?*

Pacific Daylight Time (PDT)Mountain Daylight Time (MDT)Central Daylight Time (CDT)Eastern Daylight Time (EDT)
Should be Empty:

Regional Interest Group (RIG) Application Form