MDS Endorsed Meetings Application

MDS Endorsed Meeting Application
Type of Support Requested (select all that apply)

Type of Support Requested (select all that apply)Funds to Support MDS FacultyFinancial Support for Event LogisticsFunds to support purchasing Zoom Webinar Account (MDS provides funding to support purchasing one month access to Zoom webinar. Amount awarded based upon anticipated attendance.)
A. CONTACT INFORMATION
Title of Meeting*
Organizing Body*
Institution, organization or other body
Meeting Location*
Contact Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
example@example.com
Phone Number*

Country CodeArea CodePhone Number
B. EVENT INFORMATION
Meeting Website*
Meeting Start Date*

MonthDayYear
Start Date
Meeting End Date*

MonthDayYear
End Date
Person with Fiduciary Responsibility (Name, Title)
Location where Financial Accounts are Held
Planning Committee Members*
Briefly describe the meeting:*
What language(s) will the meeting be presented in?*
Anticipated Attendance (#)*
Recommended Audience (select up to 2)*

ClinicianFellow / Resident / StudentResearcherHealth ProfessionalOther
Clinician - please specify:*

Movement Disorder SpecialistGeneral NeurologistPrimary CareResearcherOther
Health Professional - please specify:*

Nurse / Nurse PractitionerPhysio / Physical TherapistOccupational TherapistSpeech TherapistPhysician AssistantGenetic CounselingPsychologistOther
Upload the Event Program / Schedule containing Names of Faculty*

Cancelof
Please note only applications that provide complete information will be considered.
Please allow 5-7 weeks for review.
PROPOSED MDS FACULTY

Select # of Faculty

1234

Faculty 1
Name of Faculty 1

First NameLast Name
Institution
City, Country

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email
example@example.com
Is faculty an MDS Member?

YesNoUnsure
Lecture Title(s)
Please indicate how this faculty member will be giving their lecture:*

OnlineIn-Person

Faculty 2
Name of Faculty 2

First NameLast Name
Institution
City, Country

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email
example@example.com
Is faculty an MDS Member?

YesNoUnsure
Lecture Title(s)
Please indicate how this faculty member will be giving their lecture:*

OnlineIn-Person

Faculty 3
Name of Faculty 3

First NameLast Name
Institution
City, Country

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email
example@example.com
Is faculty an MDS Member?

YesNoUnsure
Lecture Title(s)
Please indicate how this faculty member will be giving their lecture:*

OnlineIn-Person

Faculty 4
Name of Faculty 4

First NameLast Name
Institution
City, Country

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email
example@example.com
Is faculty an MDS Member?

YesNoUnsure
Lecture Title(s)
Please indicate how this faculty member will be giving their lecture:

OnlineIn-Person

MDS Endorsed Meeting Application

A. CONTACT INFORMATION

B. EVENT INFORMATION

PROPOSED MDS FACULTY