MS MENTORSHIP FORUM 2025 PREVIOUS SCHOLAR AWARDEE UPDATE INFORMATION

MS MENTORSHIP FORUM SCHOLAR UPDATE – REQUIRED for 2025

The Consortium of Multiple Sclerosis Centers (CMSC) and Foundation of the Consortium of Multiple Sclerosis Centers (FCMSC) are committed to providing specialized training and development initiatives to encourage healthcare trainees and professionals to consider an initial focus or advanced specialization training in MS.

The MS Mentorship Forum (MF) is a unique educational program designed for trainees who are interested in or have recently entered the field of MS practice. The 2025 MF will be held on Tuesday, May 27, the day before the start of the 2025 Annual Meeting of the CMSC at the Phoenix Convention Center, Phoenix, AZ, May 28-31, 2025.

You have joined us for the MF in the past. If you are interested in attending the 2025 MF, you must complete and submit this form; you will be put on a waitlist. Approved Scholars will need to arrive by Monday (5/26/25) to attend the MS Mentorship Forum starting Tuesday morning. Scholars must be available to attend events listed below:

Tue, May 27, 2025 Full-Day MS Mentorship Forum (breakfast, lunch and dinner included)
Wed, May 28, 2025 Evening Scholar Reception
Thu, May 29, 2025 FCMSC Scholar Recognition Luncheon

DEADLINE. Please complete and submit the form no later than Jan 31, 2025. If you have questions about this program, contact Nancy Chazen at nancy.chazen@mscare.org.

SCHOLAR ATTENDANCE

YES, I am available to attend the Mentorship Forum in Phoenix, AZ and would like to be included on the waitlist. I will complete the information below.

NO, thank you. I cannot attend this year but here’s my updated information for future events.

Name:

First Name

Last Name

Credentials:

Title:

NPI#:

State and License number:

Current Position/Training Status:

PGY

Fellow

Other

Please specify the year of your position/training status (i.e. PGY-2, 1st Year Resident, or other)

If not Neurology, please indicate your specialization:

Applicant Address:

City, State/Province/ Zip

Country

Primary Phone:

Primary Email

Affiliation:

Affiliation Phone:

Affiliation Address:

City, State/Province/ Zip

Country

Emergency Contact Name:

Emergency Contact Phone Number:

Emergency Contact Email Address:

BREAK OUT SESSION:

Please click the dropdown list and select your top 3 preferences for a break out session.

1st Choice:

2nd Choice:

3rd Choice:

QUESTIONS FOR THE MENTORSHIP FORUM:

So that we can provide you with the best experience, please take a minute to provide us with up to 2 questions that you would like to be addressed at the Mentorship Forum. Your response is very critical to the planning of this meeting.

Question 1:

Question 2:

Director/Supervisor/Mentor Name:

Director/Supervisor/Mentor Email:

Applicant Signature:

Date:

DEADLINE. Submit the form no later than Jan 31, 2025.

If you have any questions about the program, please contact Nancy at 201-487-1050 x107, nancy.chazen@mscare.org.