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

Email:  joanb@amssm.org
Phone:  913-327-1415
Select from drop down menu the category of membership you are applying for:
 
First Name:
Last Name:
Maiden Name:
Degrees:
Date of Birth:
Sex:
Male: Female:
 
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:
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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 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)
 
A. Teams Covered
Scholastic School:


Sport:


Collegiate School:


Sport:


Division I
Division II
Division III
NAIA
NJCAA
Professional Name of Team Covered:


AFL - Arena Football League
CFL - Canadian Football League
LPGA - Ladies Professional Golf Association
MILB - Minor League Baseball
MLB - Major League Baseball
MLS - Major League Soccer
MMA - Mixed Martial Arts
NASCAR - National Association for Stock Car Auto Racing
NBA - National Basketball Association
NFL - National Football League
NHL - National Hockey League
PGA - Professional Golfers Association of America
WNBA - Womens National Basketball Association
WWF - World Wrestling Federation Entertainment, Inc.
Olympic / Paralympic Country Representing:


Sport:


Military Branch Representing:


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.
CAQ 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):
   
 
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.
Ethnic Background:

AMSSM is pleased to announce Össur has provided a grant through the AMSSM Foundation that will cover the cost of AMSSM Fellowship membership for the 2017 calendar year on a first-come, first-served basis until the funds are exhausted.

Eligibility for the Össur Americas grant:

  • Current sports medicine fellow in an accredited sports medicine fellowship program in good standing with the AMSSM regarding the Match Code of Ethics.
  • Renew/join by before the funds are exhausted or by January 5, 2017 whichever comes first.
  • To accept the Össur grant, please select (Fellowship ÖSSUR Member) on the membership category drop down above.
  • Your Fellowship must have participated in the match (military programs are excluded from this criteria).
 
MEMBERSHIP DUES
Please check the appropriate box. Active Member Membership: $350.00 USD
Print Subscription of the Sports Health Journal: A Multidisciplinary Approach. Included
Print Subscription of the Clinical Journal of Sport Medicine. $97.00 USD
 
You may pay with check or credit card. If paying by credit card, please complete the information below.
If you will be sending a check, please make check payable to AMSSM in US dollars.
Payment Type:
Card Type:
Billing First Name:
Billing Last Name:
Billing Address:
Billing State:
Billing ZIP / Postal Code:
Card Number:
Expiry Date:  / 
CVV Number:  [help?]
Please make check payable to AMSSM, to be mailed separately - Please indicate on check that payment is for membership and must include applicant's name.
 
The candidate hereby states all information contained in this application is true and correct. The candidate understands any false statement contained may result in future revocation, suspension or cancellation of membership issued in reliance upon the accuracy of the information provided. The candidate understands the AMSSM may contact any reference listed to verify accuracy of this application.
 
Electronic Signature: Application Date: Dec 16, 2018
 
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AMSSM CRITERIA FOR MEMBERSHIP
 
CRITERIA ONE AND TWO:
  • Must be a licensed, practicing physician of either allopathic (MD) or osteopathic (DO) medicine.
  • Board certified in family medicine, internal medicine, pediatrics, emergency medicine, or physical medicine and rehabilitation. Candidates can be grandfathered without board certification until December 31, 1999.
  • Affiliate members must be Board Certified in their specialty (e.g. orthopedics, neurology, radiology, surgery, etc.)
CRITERIA THREE:
  • Recommendation: Identify one AMSSM member as a reference.
 
CRITERIA FOUR: (All candidates must include a current Curriculum Vitae please highlight pertinent sports medicine information)
  • Active, Associate, Affiliate candidates: required to complete sections A - J below
  • Fellowship member candidates: do not need to fulfill point criteria, only section G below
  • Must have a demonstrated commitment to sports medicine. 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.

To qualify for Active or Affiliate member status, the candidate must have a minimum of 25 points. To qualify for Associate member status, the candidate must have a minimum of 15 points. Qualifying points are awarded as listed below. The final awarding of points is at the discretion of the Membership Committee. A maximum of 73 points are available.
 
Points
A. Team Physician
10
 
B. Twenty Percent of Clinical Practice in Sports Medicine

(this is in-office and does not include time spent as a team physician)
... Other Equivalent Involvement*
10
 
C. Years of Sports Medicine Practice

One point is allowed for every year of practice in sports medicine after completing residency/fellowship training.
10
maximum
 
D. AOASM Certificate on Competence in Sports Medicine
5
 
E. Certificate of Added Qualifications (CAQ) in Sports Medicine
5
 
F. Credential in Sports Medicine (International Equivalent)
5
 
G. Sports Medicine Fellowship Completed
10
 
H. Publications in Sports Medicine


Refereed Journals 2.0/article
Non-refereed Journals 1.5/article
Other Journals .5/article
Book Chapters 2.5/chapter
10
maximum
     
I. Research in Sports Medicine
3
 
J. Teaching Responsibilities Presentations at


National Meetings 2.0/presentation
State/Regional Meetings 1.5/presentation
Local Meetings 1.0/presentation
Teaching of fellows, residents and medical students 3.0
10
maximum
 
* The AMSSM recognizes there may be extenuating circumstances under which candidates may earn points for other significant involvement. For example, serving in a significant administrative capacity in sports medicine might substitute for serving as a sports medicine physician.