JO I N T H E WO R L D L E AD E R S I N O R T H O P AE D I C S ! IS AKOS The International Society of Arthroscopy , Knee Surgery and Orthopaedic Sports Medicine 2678 Bishop Drive, Suite 250 San Ramon, CA 94583-2338 USA Tel: +1 (925) 807-1197 Fax: +1 (925) 807-1199 E-mail: isakos@ isakos.com Web: www.isakos.com IS AK OS の使命 ISAKOSは、 関節鏡、膝関節手術そして 整形外科スポーツ医学における 教育研究と治療の 世界的な交換と普及を 促進します。 ISAKOSに入会すると以下のサービスを 受けることができます €・ジャーナル（The Journal of Arthroscopic and Related Surgery）の 自動年次申込。 € ・ISAKOS登録料の割引。 € ・ISAKOS認定の講座や教育センター、ISAKOS後援の会議への参加機会。 ・年二回のニュースレーター送付。 € ・世界各国の整形外科のリーダーとの交流。 € €・国際的な考え方を通し、自己の整形外科医としてのlevelが向上で 機会を得ることができます。 €・ISAKOSホームページの会員専用ページへのアクセス権限。 以下の会の一つに属していれば簡単に メンバーになることができます。 以下の会の一つに属するメンバーは、推薦人なしでAssociate Memberと して入会資格を得ることができます。 Associate Memberに申し込む場合は推薦状不要です。 入会申込書に必要事項を記載する際、どの会のメンバーであるかについ ても示してください。 €・The American Orthopaedic Society for Sports Medicine (AOSSM) €・The Arthroscopy Association of North America (AANA) € The Asia Pacific Orthopaedic Society for Sports Medicine (APOSSM) €・ € The Knee and Orthopaedic Sports Medicine Section of the Asia €・ Pacific Orthopaedic Association (APOA) € The E uropean Society of Sports Traumatology, Knee Sugery, r and €・ Arthroscopy (ESSKA) €・ € The Latin American Society of Arthroscopy, Knee Sur gery, and Sports Medicine (SLARD) A P P L Y T O B E C O M E A N I S A K O S M E M B E R T O D AY ! JO I N T H E WO R L D L E AD E R S I N O R T H O P AE D I C S ! 会員の種類 あなたの申込書を検討し、主要な二つの会員のいずれかに認定します。 Associate Membership Active Membership 医学または科学分野に興味を持つ方で、関節鏡手術、膝手術、ス ポーツ医学に感心を持つ方が、Associate Membersになる資格を 有します。AANAに属する方以外は、Associate Memberになると雑 誌"Arthroscopy" "The Journal of Arthroscopic and Related Surgery" が送られてきます。 Associate Memberには投票権はありません。 各国の学会において認められた整形外科医、筋骨格系専門医、 リウマチ分野の専門医あるいはそれと同様の資格をもつ方が対 象になります。AANAに属する方以外は、Active memberになる と雑誌"Arthroscopy""The Journal of Arthroscopic and related Surgery"が送られてきます。Active Membersはすべての会議に おいて投票権があります。志願者は資格を得るためにISAKOS会 議に一度出席しているか、次の会議に出席する必要があります。 ISAKOS会員の申し込み方法 6週間で会員になることができます。指示に従い入会申込書にご記入ください。 履歴書を添付する必要はありません。 Associate Membershipは、申込書受理後6週間で認定されます。 Associate Memberとして入会を希望される方は、以下の手順で新生 してください。 €・入会申込書SectionⅠ,Ⅱ,Ⅲ,Ⅴ,Ⅵへ明瞭に記載してください。 € ・前頁に記載されているいずれかの学会の会員でない方は、地域 のISAKOS Active会員による推薦状（Section Ⅳ A）が必要 です。 €・入会と同時に会費US 275ドルを納入してください。 Associate Memberの会員申込者で認められた方は、特別な申し出が 無い限り自動的に次のcommittee meetingでActive memberへの昇格 が検討されます。 * 申込者の地域にISAKOSのActive会員が居住していない場合は、前頁 の列挙した地方学会の一つからの正会員の証明で結構です。 Active Membership は、Membership Committee meetingで係属中の 申込書の再審査の後、与えられます。 Membership Commitee はアメリカ整形外科学会（AAOS）の年次総会 もしくはISAKOSの会の時に開催されます。Active会員の審査はAAOS の年次総会と2年に1度のISAKOSの会にて行われます。 Active Memberになるためには、最低限一回のISAKOS会議に出席す る必要があります。Active Memberに応募するためには、地域別で の学会会員の有無にかかわらず、次の手順で申請する必要があり ます。 € ・入会申込書SectionⅠ,Ⅱ,Ⅲ,Ⅴ,Ⅵへ明瞭に記載してください。 ・ISAKOSのActive会員による推薦状（Section Ⅳ A）を提出く € ださい。（第二番目のスポンサーからの推薦状があれば更に好 ましい。（Section Ⅳ B）） ・会員申し込みと同時に、US 275ドルの年会費を支払う必要があ ります。 ** AANA会員は、ISAKOS年会費をUS 200ドルのみ支払うと、 AANA会員である間、雑誌購読を継続できます。 ISAKOSの最新情報 € 世界各地の地方の学会と共同し、関節鏡、膝関節手術そして整形外科スポーツ医学に関する知識を高め、研究を促進します。 € € € ISAKOSは1995年に国際膝関節学会（ISK）と国際関節鏡学会（IAA）が合併して結成されました。 ISAKOSは、整形外科医、レジデント、そして医療関係者などを含め1700人を超える会員数を有しています。 ISAKOSの会員は全世界に広がっており、会員を有する国はArgentineからVenezuelaまでの国になっています。 € Associate memberとして認められた応募者は6週間で会員になることができます。 S E N D I N Y O U R M E M B E R S H I P A P P L I C AT I O N T O D A Y ! International S ociety of Arthroscopy, K nee S urgery and Orthopaedic S ports Medicine 2678 Bishop Drive, Suite 250 € San Ramon, CA 94583-2338 € USA Tel: +1 (925) 807-1197 € Fax: +1 (925) 807-1199 € E-mail: isakos @ isakos.com € Web: www.isakos.com Application for Membership 以下の申込書へ、続け字でない英語ですべての項目についてご記入いただき、推薦状を添え、ISAKOS事務局へご提出くだ さい。詳しくは申込書後部をご参照ください。 I. S tandard Personal Information Name: ________________________________________________________________________________________________________________________________________________ Last (Family) Name First (Given) Name Middle Name Title: ________________________________________________________________________________________________________________________________________________ (E x: MD, PhD, FRCS, etc.) Mailing Address: ________________________________________________________________________________________________________________________________________________ Street Department/Suite ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ City State or Province ZIP or Postal Code ________________________________________________________________________________________________________________________________________________ Country Date of Birth: Telephone Number: __________________________________________________________________________________________________________________ Country Code City Code Number Fax Number: __________________________________________________________________________________________________________________ E -mail Address: __________________________________________________________________________________________________________________ ____________________________________________________________________ Day/Month/Year Sex: Male Female Are you a member of any of the following regional societies? (check all that apply) AANA AOSSM APOSSM E SSKA SLARD APOA Which ISAKOS Congresses have you attended? (check all that apply) None 1995 ÐHong Kong 1997 ÐBuenos Aires 1999 ÐWashington, D.C. 2001 ÐMontreux 2003 ÐAuckland 2005 ÐHollywood, FL 2007ÐFlorence II. S tandard E ducation Information INSTITUTION A. Undergraduate: DEGREE(S) EARNED DATE(S) EARNED TOPIC(S) ________________________________________________________________________________________________________________________________ B. Medical University: ________________________________________________________________________________________________________________________________ C. Internship(s): ________________________________________________________________________________________________________________________________ D. Residency: ________________________________________________________________________________________________________________________________ E . Fellowship(s): ________________________________________________________________________________________________________________________________ F. Publications/Presentations: Please attach a list to this application. G. Grant(s), Honor(s), Other Scientific Contribution(s): Please attach a list to this application. Revised 9/06 H. Medical Society Membership(s): ____________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________ I. Professional Association Affiliation(s): ____________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________ J. Attendance at Arthroscopy, Knee or Sports Medicine related Course(s), Meeting(s), Symposium(s): ______________________________ ________________________________________________________________________________________________________________________________________________________________________________ III. Standard Practice Information A. Academic Affiliation(s): ________________________________________________________________________________________________________________________________ B. Hospital Affiliation(s): ________________________________________________________________________________________________________________________________ C. Practice Setting: D. Number of Cases/Year: ❐ Solo ❐ Orthopaedic Group ________Arthroscopy ________ Knee ❐ Multi-specialty Surgery ________Orthopaedic Sports Medicine E. Begin date of orthopaedic practice: ________________________________________________________________________________________________ F. Practice History (current to past): Place: ______________________________________________________________________________________________________________________ Length: ________________________ ______________________________________________________________________________________________________________________ ________________________ ______________________________________________________________________________________________________________________ ________________________ IV. Confidentiality Clause-Agreement of Confidentiality “The International Society for Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine has agreed to treat the entire contents of this application, including all inquiries or investigations made pursuant thereto and all fruits thereof as privileged and confidential materials not subject to publication, dissemination or private or in camera inspection. In consideration of that Confidentiality Agreement I make the following agreement. I specifically authorize the Society to make whatever inquiries and investigations it deems necessary to ascertain and verify my qualifications, credentials, professional standing and moral or ethical character. I further covenant and agree that I will not seek or cause to attempt to seek or cause any disclosure of production, whether private, public or in camera of the contents of any application file of any candidate for membership in the Society of whatever classification, including proceedings of the Board or any Committee pursuant thereto, or the products, fruits, or sources of any inquiries or investigations made pursuant hereto whether said disclosure be by operation or process of law or otherwise. Processing and consideration of the application will involve participation by numerous members of the Society on behalf of the Society; all activities concerning such processing and consideration shall not be considered to be a disclosure, production, inspection, nor dissemination by the members of the Society participating therein. In further consideration of the Society’s processing and consideration of this application, I specifically covenant and agree that I will not commence, bring or institute any proceedings, suit or action in any court or other tribunal or forum directed against or to the Society or any member thereof in any way concerning, pertaining to or arising out of the consideration, processing, rejection, deferment, acceptance or other handling of this application, acceptance or other handling of this application for membership in the Society or any of the inquiries or investigations conducted in connection therewith.” Signature: ________________________________________________________________________________ Date: ________________________________________________________________________ V. Membership Payment: Payment must accompany your application. I will pay this year’s membership dues with: ❐ ❐ Enclosed check DRAWN ON AN AMERICAN BANK IN U.S. DOLLARS Credit Card (select card type and complete the information below): Card Type: ❐ VISA Card Number: ❐ MasterCard Expiration Date: ______________________________________________________________________ ❐ American Express Signature: ________________________________________________________________________ ______________________________________________________________________________ VI. S ponsor Form A Applicant’s Name: ________________________________________________________ SponsorÕ s Name: ________________________________________________________ Active Membershipの会員申込者は、日本のISAKOSのActive会員による推薦状を少なくとも一つは提出しなければなりま せん。推薦者のサインの無い書類は不完全とみなされ、審議対象から外されます。推薦者が住んでいる地域に見つから ない場合は、あなたが属する地方学会の正会員の証明を提出してください。 スポンサーへの注意；English Block Letterの書式にて印刷もしくはタイプいただき、日付とサインを記載ください。 あなたが提供された情報は、membership committeeにてreviewされるのみであり、記載された すべての項目に関しての秘密は守られます。 1. Are you an Active Member of ISAKOS? Yes No 2. How long have you known the applicant? 0 - 5 years 5 - 10 years 3. In what capacity have you worked with the applicant? Partner 4. Fellowship Residency Program 10 or more years Other: ______________________________________________________________ Describe your current professional affiliation with the applicant: ________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ 5. Describe your opinion of the applicantÕ s fund of knowledge and skills: Outstanding 6. Unsatisfactory Above Average Average Below Average Unsatisfactory Above Average Average Below Average Unsatisfactory Below Average Unsatisfactory Describe your opinion of the applicantÕ s surgical judgment and care: Outstanding 9. Below Average Describe your opinion of the applicantÕ s standard of patient care: Outstanding 8. Average Describe your opinion of the applicantÕ s teaching ability: Outstanding 7. Above Average Above Average Average Do you recommend the applicant for Active Membership in ISAKOS? Comments: Yes No ________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________ Print Full Name __________________________________________________________________ Signature ____________________________________________________________________ Date ________________________________ Upon completion of this sponsor form, please fold, seal with tape and affix first-class postage. Mail directly to the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) office. or FAX: +1 (925) 807-1199 Thank you for your assistance. ISAKOS 2678 Bishop Drive, Suite 250 San Ramon, CA 94583-2338 USA From: Affix First-Class Postage Here VII. S ponsor Form B Applicant’s Name: ______________________________________________ (OPTIONAL BUT RE COMME NDE D FOR APPLICANTS WHO ARE NOT ME MBE RS OF RE GIONAL SOCIE TIE S) SponsorÕ s Name: ______________________________________________ Active Membershipの会員申込者は、日本のISAKOSのActive会員による推薦状を少なくとも一つは提出しなければなりま せん。推薦者のサインの無い書類は不完全とみなされ、審議対象から外されます。推薦者が住んでいる地域に見つから ない場合は、あなたが属する地方学会からの正会員の証明を提出してください。 スポンサーへの注意；English Block Letterの書式にて印刷もしくはタイプいただき、日付とサインを記載ください。 あなたが提供された情報は、Membership Committeeにてreviewされるのみであり、記載された すべての項目に関しての秘密は守られます。 1. Are you an Active Member of ISAKOS? Yes No 2. How long have you known the applicant? 0 - 5 years 5 - 10 years 3. In what capacity have you worked with the applicant? Partner 4. Fellowship Residency Program Describe your current professional affiliation with the applicant:: 10 or more years Other: ______________________________________________________________ ______________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ 5. Describe your opinion of the applicantÕ s fund of knowledge and skills: Outstanding 6. Unsatisfactory Above Average Average Below Average Unsatisfactory Above Average Average Below Average Unsatisfactory Below Average Unsatisfactory Describe your opinion of the applicantÕ s surgical judgment and care: Outstanding 9. Below Average Describe your opinion of the applicantÕ s standard of patient care: Outstanding 8. Average Describe your opinion of the applicantÕ s teaching ability: Outstanding 7. Above Average Above Average Average Do you recommend the applicant for Active Membership in ISAKOS? Comments: Yes No ________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________ Print Full Name __________________________________________________________________ Signature ____________________________________________________________________ Date ________________________________ Upon completion of this sponsor form, please fold, seal with tape and affix first-class postage. Mail directly to the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) office. or FAX: +1 (925) 807-1199 Thank you for your assistance. ISAKOS 2678 Bishop Drive, Suite 250 San Ramon, CA 94583-2338 USA From: Affix First-Class Postage Here
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