October 14to 20, 2012

The Oak RidgeHotel & ConferenceCenter

Chaska, Minnesota

The North American Metabolic Academy

The Society for Inherited Metabolic Disorders (SIMD) has established the North American Metabolic Academy (NAMA) to provide a forum in which medical genetic and biochemical genetic trainees can buildtheir knowledge basefor inborn errors of metabolism and can gain exposure to the diagnosis and management of metabolic diseases.

Eligibility

The course is open to trainees in Medical Genetics and Biochemical Genetics (preference given to first-year trainees). Applicants must be nominated by their program director or an SIMD member.Nurse practitioners working in the field of metabolism are also welcome to apply. SIMD requires that all applicantsor their programs covertheir expenses. Scholarships forregistration fees are available.Space permitting, a limited number of course slots may be open to other trainees or interested academic physicians.

Applicant contact details

Name:______

Home mailing address:______

Phone:______

Email:______

Current institution:______

Position title:______

I am applying as part of the sponsor recognition program:

______

Sponsoring CompanyCompany Contact (Name/Phone Number)

Please submit an NIH-style CV with your application.
Education/training
(Begin with baccalaureate or other initial professional education, such as nursing, and include postdoctoral training)
Institution and location / Degree
(if applicable) / Year(s) / Field of study

Nominator

All trainee applicants and nurse practitioners must be nominated for attendance by their program director or an SIMD member.

I, the undersigned, nominate ______to attend SIMD NAMA.

Name:______

Email:______

Office phone:______

Fax:______

Signature:______

Registration Fee

Applicant / Registration Fee* / Submit completed applications to / Scholarship Notes
Academic Trainee / $1,000 / SIMD NAMA / Eligible for $500 scholarship through SIMD.
Academic
Non-Trainee / $1,500 / SIMD NAMA / Not applicable.
Non-Academic/
Non-Trainee professional / $3,000 / SIMD NAMA / Not applicable.
Nurse Practitioner / $1,000 / SIMD NAMA / Eligible for $500 scholarship through SIMD.

*Registration fees cover meals, lodging, and all learning materials for the 6-day course.

Scholarships

Scholarships of $500 per person are available toacademic trainees and nurse practitioners. Scholarships areapplied toward the registration fee for SIMD NAMA.

□ I am an academic trainee and would like to be considered for a SIMD NAMA scholarship.

□ I am a nurse practitioner and would like to be considered for a SIMD NAMA scholarship.

For full scholarship information and eligibility criteria, please contact Dr. MarkKorson at .

I certify that all information submitted as part of my SIMD NAMA application is correct and is an accurate representation of my qualifications. I understand that if accepted, I will be responsible for my own travel expenses and other costs.

______

Name (please print)SignatureDate

Please send the completed application form with CV by email to:
Leslie Lublink ()

Please use the subject line: “SIMD NAMA Registration Request” and include the

application form and other documentation as attachments.

Applications will not be considered until all application materials are provided and complete.

Applications will not be considered until all application materials are provided and complete.