Student Society Registration Form 2009-2010

2009-2010 STUDENT SOCIETY REGISTRATION FORM

To be fully registered, a society must submit the information requested below. If you have any questions please contact Student Academy Staff Advisors Shannon Faherty or Dave McGuire II, at 703-836-2272 ext. 3311 or students@aapa.org. This form is valid until 8/31/10.

Student Society Information:

* Name of Student Society:

* PA Program:

* School Term:

School Term: The start and end dates of your program, i.e. September 2009 through May 2010 or January 2010 through December 2010.

Student Society Mailing Address:

City:

State:

Zip Code

Student Society Website:

* Faculty Advisor Name:

Faculty Advisor AAPA ID # - if known:

* Faculty Advisor Email:

Student Society Officer Information:

We strongly encourage you to provide email addresses for all officers. Electronic communication is the fastest and most cost-effective means of communication available to most students, therefore the Student Academy relies heavily on email communication and use of the SAAAPA website. Please note that according to SAAAPA bylaws, all student society officers must be AAPA members.

1. President:

President Name:

President Address:

President City:

President State:

President Zip Code:

President Cell Phone Number:

President AAPA Membership ID #:

President Email:

2. Vice President:

VP Name:

VP Address:

VP City:

VP State:

VP Zip Code:

VP Cell Phone Number:

VP AAPA Membership ID #:

VP Email:

3. Secretary:

Secretary Name:

Secretary Address:

Secretary City:

Secretary State:

Secretary Zip Code:

Secretary Cell Phone Number:

Secretary AAPA Membership ID #:

Secretary Email:

4. Treasurer:

Treasurer Name:

Treasurer Address:

Treasurer City:

Treasurer State:

Treasurer Zip Code:

Treasurer Cell Phone Number:

Treasurer AAPA Membership ID #:

Treasurer Email:

5. Student Historian:
This position serves as a liaison to coordinate activities between their student society and the Society for the Preservation of Physician Assistant History. The student historian shall report all activities to the Society for the Preservation of Physician Assistant History.

Historian Name:

Historian Address:

Historian City:

Historian State:

Historian Zip Code:

Historian Cell Phone Number:

Historian AAPA Membership ID #:

Historian Email:

EAC/CCSR/HOD/SDCR Designation:
The AOR and HOD representatives should be two different individuals as the meetings run concurrently at AAPA's annual conference. To be eligible to participate in the SAAAPA National Medical Challenge Bowl each Student Society must register an EAC, CCSR, AOR, HOD, and SDCR. For more information, contact Student Academy staff advisors: Shannon Faherty or Dave McGuire II, at 703/836-2272, ext. 3311 or students@aapa.org.

Even if you are unsure about attending the annual conference, we ask that you provide us with an AOR and HOD contact so that your program will be kept up to date on important national activities.

6. Constituent Chapter Student Representative (CSSR):
This position represents your program to the AAPA constituent chapter on the state level. In states where there is more than one PA program, there may be a selection process determined by the state chapter to choose the student representative. For more information on your state constituent chapter policies, contact your local chapter.

CCSR Name:

CCSR Address:

CCSR City:

CCSR State:

CCSR Zip Code:

CCSR Cell Phone Number:

CCSR AAPA Membership ID #:

CCSR Email:

7. External Affairs Chair (EAC):
This position serves as a liaison to coordinate activities and public relations efforts between their student society and external groups. The EAC shall report all activities to both the SAAAPA Director of External Affairs Senior and Junior. The responsibilities of the EAC should include, but are not limited to the following: Coordinate activities and public relations efforts between the student society and external groups; these groups include, but are not limited to: other medical professionals (MD, DO, PT, OT, nurses, speech, etc.), city organizations, county organizations, state organizations, national organizations, and other community related organizations.

EAC Name:

EAC Address:

EAC City:

EAC State:

EAC Zip Code:

EAC Cell Phone Number:

EAC AAPA Membership ID #:

EAC Email:

8. AOR Representative:
This is your program's student representative to the 2010 Assembly of Representatives, the legislative body of the national Student Academy, which will meet May 29-30, 2010, in Atlanta, GA, at the AAPA's 38th Annual PA Conference. A student representative is required of every PA program.

AOR Rep Name:

AOR Rep Address:

AOR Rep City:

AOR Rep State:

AOR Rep Zip Code:

AOR Rep Cell Phone Number:

AOR Rep AAPA Membership ID #:

AOR Rep Email:

9. AOR Alternate:
Your program may also designate an AOR alternate. The AOR alternate will not be allowed on the floor to introduce new business, make a motion or vote unless the seated representative to the AOR relinquishes their seat either temporarily or permanently. The AOR alternate must leave the floor once the seated AOR representative returns. Materials will be sent only to the seated AOR representative who must distribute copies to the alternate and other students within the program.

AOR Alt Name:

AOR Alt Address:

AOR Alt City:

AOR Alt Rep State:

AOR Alt Zip Code:

AOR Alt Cell Phone Number:

AOR Alt AAPA Membership ID #:

AOR Alt Email:

10. HOD Student Delegate:
The student delegation to the AAPA House of Delegates consists of 14 delegates and an unlimited number of alternates. The delegates are chosen by a lottery system and each program may only submit one name for this position. Your program's HOD student delegate will serve as a delegate or alternate (depending on the lottery results for 2010) in the 2010 student delegation which will represent the Student Academy in the AAPA's House of Delegates at the AAPA's 38th Annual PA Conference in Atlanta, GA, May 29-31, 2010.

HOD Name:

HOD Address:

HOD City:

HOD State:

HOD Zip Code:

HOD Cell Phone Number:

HOD AAPA Membership ID #:

HOD Email:

11. Student Diversity Committee Representative (SDCR):
The SDCR serves as the liaison between the Student Academy and the student society regarding diversity issues affecting their classmates as future colleagues and health care providers. The elected individual need not be a minority, but must have a strong interest in supporting and promoting the education of students on issues of diversity. The duties of this office shall include but not be limited to: coordinate, with the aid of the regional chair, local activities and community outreach projects and provide monthly updates regarding activities at his/her program that serve to promote cultural competency to his/her regional chair.

SDCR Name:

SDCR Address:

SDCR City:

SDCR State:

SDCR Zip Code:

SDCR Cell Phone Number:

SDCR AAPA Membership ID #:

SDCR Email:

Student Society Membership List:

* An electronic copy of your student society membership list must be submitted annually, per SAAAPA policy SA-A-200.6.2.3, "The student society registration must be accompanied by the society's proposed bylaws and the student society membership list." The membership list should include the name, email address and phone number of each student society member.

Student Society Bylaws:

* An electronic version of your bylaws must be submitted annually. Please copy and paste your student society bylaws below.

If you are unable to copy and paste your membership list or your bylaws into the above spaces, please provide your information via email to Dave McGuire II, Student Academy Staff Advisor at students@aapa.org.

* Indicates Response Required