Application for FAWM Affiliation

*Note: CME credit purchase remains a separate WMS function and must be applied for separately. Please contact the WMS administrative office at fawm@wms.org for specific CME related questions.

1. Title of host organization:
2. Title of activity:
3. Brief description of activity (i.e. workshop, seminar, CME conference, certification course)
4. Provide overall core course objectives along w/ detailed plans (or equivalent) for each separate lecture in series submitted, i.e.: Course Objectives a) Educate participants in the pathophysiology, recognition, and treatment of medical issues commonly encountered in wilderness environments and remote settings. b) Develop a set of treatment priorities for care of the sick or injured in wilderness settings. c) Establish base of knowledge in basic aspects of improvised care, rescue, and evacuation Program Lesson Plans by Topic Topic #1: PATIENT ASSESSMENT IN WILDERNESS SETTINGS Lession #1 Outline: Initial patient assessment and treatment priorities in remote settings Topic #2: ALTITUDE ILLNESS: PREVENTION AND TREATMENT Lession #3 Outline: Pathophysiology, diagnosis and management of altitude related illness
5. Start and end dates of activity:
6. Total educational contact hours offered for the activity
7. Location of activity:
8. Point(s) of contact:	Primary Secondary
9. Telephone number(s)	Primary Secondary
10. Email(s)	Primary Secondary
11. Mailing address of host organization:	Street City State Zip Country

12. WMS Affiliation Options	Option 1: Purchase CME only (without FAWM credit). NOTE: This option does not give participants FAWM credit eligibility. Option 2: Purchase CME credits from the WMS -AND- FAWM credit evaluation of sessions. Option 3: Affiliate for FAWM credit evaluation ONLY (without CME).

13. Additional considerations and comments

14. FAWM Affiliation Fee Estimation	CME Credit Fee ($200+$500+$35/attendee) FAWM Credit Fee ($40, $70 or $150 + $3 w/ CME or $5 wo/ CME per attendee)
	TOTAL Estimated Fee: