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Wilderness Medical Society - WMSbrochure 1 (Page 10)

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Wilderness Medical Society - WMSbrochure 1
::FELLOW OF THE ACADEMY OF WILDERNESS MEDICINE APPLICATION
QUALIFICATION
Registrants will have completed an initial qualifying, credentialing,
or vocational degree-producing program in any recognized medical
discipline or vocation.
Qualification may be demonstrated by submission of a photocopy
of a graduation certifIcate or diploma along with verifiable contact
information at the awarding program or school.
EXPERIENCE
Registrants will have completed at least one year of professional
practice in their medical vocation or discipline after completion of
an initial qualifying program or school.
Experience may be demonstrated by submitting verifiable contact
information and a photocopy of a membership certificate or similar
documentation in a professional society, association, institution,
or employment.
CURRENCY
Registrants will, at the time of registration, be current with respect
to licensure and/or institutional registration in their respective
vocational discipline.
Proof of currency may be demonstrated by submitting a photocopy
of any current professional discipline credentials including but not
limited to state licensure or registration.
MEMBERSHIP
Registrants (Fellows and candidates) must maintain an active
membership in the WMS in order to maintain their registry status.
Membership may be demonstrated by providing a current membership
number, or a completed membership application and dues payment
with the registry application.
FEE STRUCTURE
Upon application to the registry program, applicants will pay an
initial one-time fee of $95. Registrants will pay a $25 annual fee
to maintain their candidate and Fellow status for all subsequent
years to remain active. Retroactive reviews for credit will incur a $50
administrative fee.
DISCLOSURE
The WMS is under no obligation to keep the names of individuals
listed in the registry confidential and those accepting inclusion in
the registry thereby give permission to list their names publicly in
Society related publications and website applications.
Name ____________________________________________________
Credentials ________________________________________________
Address ___________________________________________________
City __________________ State _____ Zip/Postal Code ____________
Telephone __________________________________
Email______________________________________
Fees
Academy registration fee
$95
$________
Retroactive credit review
$50
$________
(optional)
Join WMS if not a current member
Doctoral
$160 or $650 for 5 years
Non-Doctoral
$100 or $400 for 5 years
Resident
$75
Student
$50 or $175 for 4 years
WMS Membership amount
$________
Total
$________
Payment
My check is enclosed and payable to the Wilderness Medical Society
Charge to my Visa/MasterCard _______________________________
Expiration Date _______________
Signature ________________________________________________
Disclaimer
Consistent with Academy principles, the WMS does not vouch for the competency of
any individual listed in the registry. The Academy's role is limited to documenting and
verifying that individuals in the registry have met the educational criteria established by
the Academy. Documented education and/or experience should not be used to verify or
validate an individual's competency to perform any specific task or skill.
I have read and agree to the Professional Conduct Statement and understand that the
Director of the Academy of Wilderness Medicine will review and make final approval of all
applicants to the candidacy of Fellow of the Academy of Wilderness Medicine. Appeals will
be made in writing to the Academy Director.
If not able to be resolved, these will be reviewed by the WMS Executive
Committee with final decision authority resting with the WMS President.
_____________________________________________________
Signature
_____________________________________________________
Date
Mail or fax this application to:
WMS, 810 East 10th,
Lawrence, KS 66044
Telephone: 800-627-0629, ext 222
Fax: 785-843-1274
Tracking Code: SNF06

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