AMSSM NEW MEMBERSHIP APPLICATION FORM
**STOP**:  If you have ever been a member of the AMSSM, please contact the membership coordinator before completing this application.

Email:  [email protected]
Phone:  913-327-1415
Select from drop down menu the category of membership you are applying for:

 
First Name:
Last Name:
Maiden Name:
Degrees:
Pronouns:
Date of Birth:
With Which Gender Do You Identify?
 
Business Info
Business Name:
Business Address:
Business Suite:
Business City:
Business State / Province:
Business Country:
 
Business Zip Code:
Business Phone:
Website:
 
Home Info
Home Address:
Home Suite:
Home City:
Home State / Province:
Home Country

Home Zip Code:
Home Phone:
 
Contact Info
Cell Phone:
Primary Email:
Secondary Email:
Preferred Mailing Address:
 
Username:
Password (8-12 characters, using numbers, symbols, lower and uppercase for strength):
A copy of your Curriculum Vitae (C.V.) is required when submitting your application. On your C.V., please highlight relevant publications, research and presentations/teaching in sports medicine.
curriculum vitae (Word Docs Files Only)
 

Criteria #1 through #4 must be met to be considered for membership. CLICK HERE to view list of criteria.
 
CRITERIA #1 and #2  
Medical School:
Date of Graduation:
Residency Training:
Institution:
Dates:

to
Specialty Board Certification:
Date:
 
CRITERIA #3  
Recommendation: (identify one AMSSM member as a reference)
 
CRITERIA #4 - Must have a demonstrated commitment to sports medicine.
 
A. Teams Covered
Scholastic
Collegiate
Professional
Olympic / Paralympic
Military
Total Points (10 Points):
B.
20% of my practice is clinical sports medicine:. Other equivalent involvement. Describe 20% or "other":
Total Points (10 Points):
C.
Years of Sports Medicine Practice:. One point per year after completing residency/fellowship training:
Total Points (10 Points):
D.
AOASM Certificate of Competence in Sports Medicine:.
Total Points (5 Points):
E.
Board Certified in Sports Medicine:.
Total Points (5 Points):
F.
Credential in Sport Medicine (International Equivalent): .
Credential:
Date Earned:
Total Points (5 Points):
G.
Sports Medicine Fellowship Completed:.
Fellowship
Other Fellowship:
Program Dir.
Dates: to
Total Points (10 Points):
H.
Publications in Sports Medicine:.
Indicate publications on your enclosed CV. List points next to each article/chapter
Total Points (10 Points):
I.
Research in Sports Medicine:.
Indicate research on your enclosed CV.
Total Points (3 Points):
J.
Teaching Responsibilities:.
Indicate teaching activities on your enclosed CV. List the number of points next to presentation/ teaching experience.
Total Points (10 Points):

Do you identify as Hispanic, Latino or of Spanish origin:


Other Hispanic, Latino or Spanish origin - for example, Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian, etc.

With what race do you identify? Mark all that apply and include origin:

Please Note:
1) This is optional and has no bearing or effort on a member’s eligibility for membership or relationship with AMSSM;
2) This information will be added to the member database profile.