CMSS GLEAM 2025 Registration Form

CMSS GLEAM Program Registration Form
Registration is now open for the CMSS Governance and Leadership Excellence Across Medicine program.

You may register up to six (6) participants per organization via this form; participant details will be entered on the subsequent pages.

The fees per participant are:

CMSS Members: $1100
Non-Members: $1320

*Non-member participation is subject to CMSS approval. Registration is available for members only until January 2025. Interested non-members should contact Shaniece Rigans to express interest and receive registration details once open.

Both credit card and ACH/Invoice request options are available.

Questions? Please contact Shaniece Rigans| srigans@cmss.org
Specialty Society Name*
Society Leadership Transition Date*
i.e. November 2025. This will help us understand if participant roles may change during the course of the program.
Submitter Name*

First NameLast NameSuffix
Submitter Email*
example@example.com

Participant 1 Details
Participant 1 Name*

First NameLast NameSuffix
Participant 1 Email*
example@example.com
Participant 1 Phone Number
Please enter a valid phone number.
Assistant Name

First NameLast Name
Assistant Email
example@example.com
Participant's Specialty Society Leadership Role (by category)*

CEO/Executive DirectorBoard Chair/PresidentBoard Chair-Elect/President-ElectPast PresidentOther Volunteer LeaderSociety Staff MemberOther
Are you registering another participant?*

YesNo

Participant 2 Details
Participant 2 Name*

First NameLast NameSuffix
Participant 2 Email*
example@example.com
Participant 2 Phone Number
Please enter a valid phone number.
Assistant Name

First NameLast Name
Assistant Email
example@example.com
Participant's Specialty Society Leadership Role (by category)*

CEO/Executive DirectorBoard Chair/PresidentBoard Chair-Elect/President-ElectPast PresidentOther Volunteer LeaderSociety Staff MemberOther
Are you registering another participant?*

YesNo

Participant 3 Details
Participant 3 Name*

First NameLast NameSuffix
Participant 3 Email*
example@example.com
Participant 3 Phone Number
Please enter a valid phone number.
Assistant Name

First NameLast Name
Assistant Email
example@example.com
Participant's Specialty Society Leadership Role (by category)*

CEO/Executive DirectorBoard Chair/PresidentBoard Chair-Elect/President-ElectPast PresidentOther Volunteer LeaderSociety Staff MemberOther
Are you registering another participant?*

YesNo

Participant 4 Details
Participant 4 Name*

First NameLast NameSuffix
Participant 4 Email*
example@example.com
Participant 4 Phone Number
Please enter a valid phone number.
Assistant Name

First NameLast Name
Assistant Email
example@example.com
Participant's Specialty Society Leadership Role (by category)*

CEO/Executive DirectorBoard Chair/PresidentBoard Chair-Elect/President-ElectPast PresidentOther Volunteer LeaderSociety Staff MemberOther
Are you registering another participant?*

YesNo

Participant 5 Details
Participant 5 Name*

First NameLast NameSuffix
Participant 5 Email*
example@example.com
Participant 5 Phone Number
Please enter a valid phone number.
Assistant Name

First NameLast Name
Assistant Email
example@example.com
Participant's Specialty Society Leadership Role (by category)*

CEO/Executive DirectorBoard Chair/PresidentBoard Chair-Elect/President-ElectPast PresidentOther Volunteer LeaderSociety Staff MemberOther
Are you registering another participant?*

YesNo

Participant 6 Details
Participant 6 Name*

First NameLast NameSuffix
Participant 6 Email*
example@example.com
Participant 6 Phone Number
Please enter a valid phone number.
Assistant Name

First NameLast Name
Assistant Email
example@example.com
Participant's Specialty Society Leadership Role (by category)*

CEO/Executive DirectorBoard Chair/PresidentBoard Chair-Elect/President-ElectPast PresidentOther Volunteer LeaderSociety Staff MemberOther
To register more than six (6) people for GLEAM 2025, please contact Shaniece Rigans at srigans@cmss.org.

Payment of Fees
Fee per participant: $1,100 (CMSS Members)

Fee per participant: $1,320 (Non-Members)
Number of Participants*
Total Due
Payment method:*

Pay now with a credit cardSend me an invoice for ACH/Check payment

My Products*

USDTotal Due

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

CMSS GLEAM Program Registration Form