Award Recipient Registration - SAGES Education and Research Foundation

Name(Required)

First Last Suffix

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile Phone(Required)

Office Phone

Your Preferred Email(Required)

Academic Title(Required)

(if none, enter “none”)

Hospital Title(Required)

(if none, enter “none”)

Institution(Required)

Assistant or Contact Person Name

First Last

Assistant or Contact Person Email

Please select the award for which you are a recipient

Margrèt Oddsdòttir MD Traveling Fellowship Award

Barbara Berci Memorial Award

Excellence in Medical Leadership Scholarship

Jeffrey Ponsky Master Educator Award

Gerald Marks Rectal Cancer Award

Award includes comp SAGES meeting registration for awardee and team mate and $5,000 to cover travel and lodging expenses to attend the SAGES meeting.

Complimentary SAGES Annual Meeting registration and 2 nights’ hotel stay, if not already covered by another role.

Up to $5,000 for one of the following:

Registration and travel for an approved leadership course
Professional coaching focused on individualized leadership development

Award includes comp SAGES meeting registration, 1 comp hotel night unless provided for another role at the meeting such a serving as faculty.

A scholarship for up to $8,000 to cover expenses (i.e. room/board, transportation and the cost of the course) to attend a leadership program at an Academic Institution.

Award includes comp SAGES meeting registration, economy airfare and up to two nights comp hotel unless provided for for another role at the meeting such as serving as faculty.

Award includes comp registration to SAGES meeting unless provided for for another role at the meeting such as serving as faculty.

Will you be able to attend the SAGES Foundation Awards Luncheon to accept your Award? By selecting an option below, you acknowledge that you have received the time and date of the event?(Required)

I will be present

I am unable to be present

Registration fee for the Scientific Session portion of the SAGES Annual Meeting is waived, with the exception of hands-on course laboratories. You are welcome to bring a spouse or accompanying person with no registration fee. A special registration link will be sent upon acceptance that will enable you to register guests, and to register for social events and tours.

WIll you be bringing a guest?(Required)

Yes

Please upload a current head-shot photograph(Required)

Max. file size: 512 MB.

Please upload an abbreviated CV (4 pages or less)(Required)

Max. file size: 512 MB.