Membership Application Form

Name*

First NameLast Name

E-mail*

example@example.com

Cellular Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Industry*

What is your social media?*

How would you help members of the FOM and the organization as a whole?*

Are you willing to give members discounts on products or services you may offer?*

YesNo

How did you hear about Friends of Medicine?*

Membership Options

Elite Membership- Healthcare Professionals (Annual) $595.00
Option to have targeted marketing to groups of professionals within the FOM directory (pending approval of the board of directors - Discounted or Complimentary access to a variety of events.
Receive 1 “New Member” social media post (upon request).
Receive member only advertising and sponsorship opportunities at all events.
Opportunity to speak or host 1 event per year upon approval of the board of directors.
Opportunity to participate as a guest speaker on the Friends of Medicine Podcast, Behind the Scrubs.
Opportunity to sponsor at least 1 podcast episode on behalf of your company.
Access to participate in event and workshop committee meetings.
Opportunity to join the Members only WhatsApp group chat - up to 14 active channels to join healthy conversations with like-minded professionals, business referral opportunities and be the first to know about upcoming events and job, and busniess opportunities within the network.
Eligibiity for FOM Foundation awards.

Elite Membership - Business Professionals (Annual) $695.00
Option to have targeted marketing to groups of professionals within the FOM directory (pending approval of the board of directors.
Discounted or Complimentary access to a variety of events.
Receive 1 “New Member” social media post (upon request).
Receive member only advertising and sponsorship opportunities at all events.
Opportunity to speak or host 1 event per year upon approval of the board of directors.
Opportunity to participate as a guest speaker on the Friends of Medicine Podcast, Behind the Scrubs.
Opportunity to sponsor at least 1 podcast episode on behalf of your company.
Access to participate in event and workshop committee meetings.
Opportunity to join the Members only WhatsApp group chat - up to 14 active channels to join healthy conversations with like-minded professionals, business referral opportunities and be the first to know about upcoming events and job, and busniess opportunities within the network.

Student Membership - (Annual) $99.00
Complimentary admission to applicable FOM events.
One-time complimentary admission for one guest to any FOM event.
Opportunity to connect with groups of professionals in the medical field (program directors and coordinators from multiple specialties, specialists across the spectrum of healthcare, mentors, leaders, innovators, investors in the medical field.
Access to financial hardship grants, career advise/mentorship.
Access to wide variety of volunteer programs.
Opportunity to participate in educational workshops as volunteers, attend career day events for free.
Eligibiity for FOM Foundation awards.
Opportunity to join the Members only WhatsApp group chat - up to 14 active channels to join healthy conversations with like-minded professionals, business referral opportunities and be the first to know about upcoming events and job, and busniess opportunities within the network.

Which membership package are you interested in?*

Please provide us with phone numbers and email addresses of TWO (2) references. The references may be an FOM member or a Healthcare Professional.

FRIENDS OF MEDICINE
MEMBERSHIP AGREEMENT AND TERMS & CONDITIONS

1.     INTRODUCTION. These terms and conditions of the Friends of Medicine Foundation, Inc. (hereinafter “FOM”)set forth the legally binding agreement (hereinafter “Agreement”) between FOM and each person who applies and is accepted for membership (hereinafter “Member” or “Members”).

2.     FOM MEMBERSHIP. FOM is a not-for-profit organization which provides certain benefits such as resources, networking, and marketing opportunities for its donor Members. FOM will allow participation in its organization and enjoyment of its benefits to all Members who comply with these Terms and Conditions. FOM, from time to time, may update the Terms and Conditions of this Agreement. FOM is only responsible for written representations that it makes concerning FOM and its membership packages and is not responsible for any representations made by any other person. Any and all membership privileges obtained through this membership agreement may be revoked or changed at any time without prior notice to member.

3.     DUES. FOM membership dues are paid in the form of charitable donations and/or contributions. All funds donated and/or contributed to FOM are used to further promote FOM and create unique opportunities for its donor Members, students, and professional community. Members shall be entitled to obtain different membership packages subject to the rates set forth by FOM representatives or website. Members are responsible for all applicable contributions required to maintain their desired membership package and costs associated with attending and or participating in any FOM sponsored events. At any point during this Agreement, Member may change their membership package with written notice to FOM. If costs increase as a result of a membership change, Member will be responsible for costs incurred. All payments, donations, and/or contributions made payable to FOM are final and non-refundable under any circumstances.

4.     CODE OF CONDUCT. All Members agree to conduct themselves in a respectful manner. In addition, all Members agree to practice professional and personal integrity, objectivity, competence, and confidentiality. FOM reserves the right to revoke the membership of any Member that fails to comply with the provisions of this Code of Conduct.

5.     TERM AND TERMINATION. The term of this Agreement shall begin on the Effective Date and shall continue for a period of one (1) year (the “Initial Term”) unless terminated as provided in other provisions of this Agreement. Upon expiration of the Initial Term, Member shall have the option to renew their membership by paying the applicable renewal fee.

6.     REPRESENTATIONS, COVENANTS AND WARRANTIES OF COMPANY. FOM covenants and represents to Members that it will comply with all applicable laws and regulations applicable as a tax-exempt 501(c)(3) organization.

7.     RELEASES AND WAIVERS OF LIABILITY. All Members permit and grant permission to FOM to use their image (photographs, audio, and video) for use in promotional media publications including, but not limited to, videographic or photographic posts on social media, FOM website, newsletters, emails, and brochures. All Members agree to waive any right to inspect or approve the use of their image that may be used in conjunction with them now or in the future. All Members and his or her spouse, heirs, legal representatives, successors, and assigns agree to indemnify and hold harmless FOM for any injuries sustained by the use of their image.

All Members agree to assume all of the risks of participating in any and all activities associated with FOM. All Members and his or her spouse, heirs, legal representatives, successors, and assigns agree to indemnify and hold harmless FOM from any and all injuries sustained as a result of the negligence or carelessness of FOM, other Members, and third-party contractors.

8.     NO THIRD-PARTY RIGHTS OR ASSIGNMENT. The provisions of this Agreement are for the exclusive benefit of the parties hereto. Members may not assign or transfer their membership associated with this Agreement.

IN WITNESS WHEREOF, the parties hereto have caused this Contract to be executed by their duly authorizedrepresentatives as of the date first above written.

Service Recipient:

FRIENDS OF MEDICINE FOUNDATION, INC.:

Please sign below acknowledging you have read and agree to the Membership Agreement and Terms & Condition above.

DISCLAIMER

Friends of Medicine Foundation is a 501(c)3 non profit. All proceeds go towards Friends of Medicine Foundation projects, educational workshops, events, administrative obligations, scholarships and grants.

Friends of Medicine Foundation is not a licensed investment firm, financial, legal or accounting organization and any information you gain from events and activities is intended for general informational, educational and networking purposes only and should not be considered as official business or legal advice. Results may vary, and we strongly advise consulting with a qualified professional to discuss your specific circumstances prior to making any business or career-altering decisions. We do not endorse any particular investment opportunity or company’s business to our guests but do hope that the knowledge gained from these representative professionals will better equip our guests to make educated decisions together with their own professional advisors.

Our attendees should do their own due diligence and consult with related professionals directly as needed prior to investing in or pursuing any potential opportunity. Nothing presented during these events is personalized advice or an endorsement of a particular company or investment opportunity. Any company logos displayed at our events are from sponsoring companies or partners and any decision to invest or do business with any of these sponsors or any of the professional presenters are solely your own and should only be done after your own due diligence. As always, we look forward to hosting you and hope you enjoy/learn from the content presented at our Friends of Medicine Foundation events.

All attendees permit and grant permission to FOM to use their image (photographs, audio, and video) for use in promotional media publications including, but not limited to, videographic or photographic posts on social media, FOM website, newsletters, emails, and brochures. All attendees agree to waive any right to inspect or approve the use of their image that may be used in conjunction with them now or in the future. All attendees and his or her spouse, heirs, legal representatives, successors, and assigns agree to indemnify and hold harmless FOM for any injuries sustained by the use of their image.