SAAAPA Student Society Registration Form 2011-2012

2011-2012 STUDENT SOCIETY REGISTRATION FORM

To be fully registered, a society must submit the following information:
* Four required officers - President, AOR, Outreach Chair, and State Chapter Representative - who are AAPA student members
* Student society bylaws
* Student society membership list

If you have any questions please contact Student Academy Staff Advisors Shannon Warren (571-319-4442) or Kate Detweiler (571-319-4398) or students@aapa.org. This form is valid until 8/31/12.

Please note: Any e-mail addresses entered into this form that have opted-out of AAPA e-mail notifications will not receive updates from the Student Academy. These include newsletters, student society confirmations, and handbook mailings. If you or any of your officers have previously opted-out of e-mail notifications, or believe this to be a possibility, please contact students@aapa.org.

Student Society Information:

* Name of Student Society:

* PA Program:

* School Term:

School Term: The start and end dates of your program, i.e. September 2011 through May 2012 or January 2012 through December 2012.

* Student Society Mailing Address:

* City:

* State:

* Zip Code

Student Society Email:

* Faculty Advisor Name:

* Faculty Advisor Email:

Student Society Officer Information:

We strongly encourage you to provide email addresses for all officers, as this is how the Student Academy communicates with officers of student societies. Please note that according to SAAAPA bylaws, all student society officers must be AAPA members.

1. President (REQUIRED POSITION)

President Name:

President Cell Phone Number:

President Email:

2. Vice President (OPTIONAL POSITION)

VP Name:

VP Cell Phone Number:

VP Email:

3. Secretary (OPTIONAL POSITION)

Secretary Name:

Secretary Cell Phone Number:

Secretary Email:

4. Treasurer (OPTIONAL POSITION)

Treasurer Name:

Treasurer Cell Phone Number:

Treasurer Email:

5. Student Historian (OPTIONAL POSITION)
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 Cell Phone Number:

Historian Email:

Outreach Chair/State Chapter Representative/AOR Designation:
To be eligible to participate in the Student Academy National Medical Challenge Bowl each Student Society must register an Outreach Chair, State Chapter Representative and AOR – all of these individuals are not required to attend the annual conference. For more information, contact Student Academy staff advisor: Shannon Warren (571-319-4442) or Kate Detweiler (571-319-4398) or email students@aapa.org.

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

6. State Chapter Student Representative (SCSR) (REQUIRED POSITION)
This position represents your program to the AAPA constituent chapter on the state level. This individual might work directly with the student who is an officer for the state chapter or this individual might be the officer of the state chapter, 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.

SCSR Name:

SCSR Cell Phone Number:

SCSR Email:

7. Outreach Chair (OC) (REQUIRED POSITION):
This position serves as a liaison to coordinate activities and public relations efforts between their student society and external groups and works to promote the profession with these external groups. The OC shall report all activities to both the Student Academy Director of Outreach. The responsibilities of the OC 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.

OC Name:

OC Cell Phone Number:

OC Email:

8. AOR Representative (REQUIRED POSITION)
This is your program's student representative to the 2012 Assembly of Representatives, the legislative body of the national Student Academy, which will meet in Toronto, at the AAPA's 40th Annual PA Conference. A student representative is required of every PA program.

AOR Rep Name:

AOR Rep Cell Phone Number:

AOR Rep Email:

9. AOR Alternate (OPTIONAL POSITION)
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.

AOR Alt Name:

AOR Alt Cell Phone Number:

AOR Alt Email:

10. Student Diversity Committee Representative (SDCR) (OPTIONAL POSITION)
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 Cell Phone Number:

SDCR Email:

11. Green Chair (OPTIONAL POSITION):
The Green Chair shall educate student society members on local and national "green" issues; work with campus and PA program leadership to facilitate green initiatives; increase interaction between the student society, constituent chapter, the Student Academy, and the AAPA national office with regard to green practice; maintain communication with the Regional Communications Committee or appropriate ad hoc committee chair regarding current green issues and ideas; inform the incoming class about the importance of professional involvement and AAPA membership; help maintain student society continuity from year to year by assisting the incoming class with the elections of officers, Green Chair, Assembly of Representatives, and House of Delegates student representatives.

Green Chair Name:

Green Chair Cell Phone Number:

Green Chair 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 Kate Detweiler, Student Academy Staff Advisor at students@aapa.org.

* Indicates Response Required