2024-2025 SAGES Fellowship Certification – Fee Waiver Application

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2024-2025 SAGES Fellowship Certification Application – VBA Fee Waiver

I hereby request a 2024-2025 Fellowship Certification in one of the following programs*

1. Advanced GI MIS

2. Advanced GI MIS and Comprehensive Flexible Endoscopy (Combined Single Certificate)

3. Advanced GI MIS + ACT Seal in Advanced Flexible Endoscopy ($25 fee for seal)

I have uploaded 2 videos to the VBA platform (CHiP).*

Yes

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Videos must be uploaded prior to submitting application.

Video Submission Required for Fee Waiver:

This application is only for fellows who have uploaded 2 videos to the VBA platform. If you have not uploaded your required videos, you are not eligible to submit this application with the fee waived.

To begin the process, you must first indicate your participation in the VBA pilot HERE.

Applications submitted without prior video verification will not be processed.

Attestation

I attest that the videos I submitted to SAGES meet the following conditions:*

	YES	NO
I served as the primary surgeon on the submitted procedures.
My fellowship program director or teaching faculty supervised the cases.
The assistant or supervising faculty did not provide any meaningful instruction, guidance, or intervention for the majority of the critical portions of the case related to the fundoplication (gastric and esophageal mobilization and wrap construction).
I have secured the necessary permission to grant SAGES use of de-identified data and images from the submitted videos for research and education purposes.

Application Form

01. Name:*

First Name Last Name

02. Degree(s):*

03. Email:*

04. Cell Phone:*

05. Current Home Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

06. Residency Program Name:*

06a. Residency Program Year of Completion:*

07. Fellowship Program Name:*

07a. Fellowship Program Year of Completion:*

08. Type of your Fellowship program accredited by the Fellowship Council. Please select one of the following program types. [**Attention: Bariatrics, Comprehensive Flexible Endoscopy, Foregut, and Hernia & Abdominal Wall ONLY Fellowship programs are not eligible for this application]*

Advanced GI MIS

Advanced GI MIS/Bariatrics

Advanced GI MIS/Bariatrics/Comprenhensive Flexible Endoscopy

Advanced GI MIS/Bariatrics/Foregut

Advanced GI MIS/Comprehensive Flexible Endoscopy

09. Is this program accredited by The Fellowship Council? Please contact your Program Director/Coordinator to obtain this information if needed.*

In order to complete the application for the Advanced GI MIS certificate, your Fellowship Program MUST be accredited by the Fellowship Council and also be in good standing.
You can check your program status at this link: Fellowship Program Accreditation Status

Yes

In order to complete the application for SAGES certification of your fellowship, the Fellowship Program MUST be accredited by the Fellowship Council and also be in good standing.

Please exit this application now and check with your Fellowship Program or the Fellowship Council to verify program status.

10. Fellowship Program Director Name (SAGES will invite your Program Director to complete an online survey)*

First Name Last Name

11. Fellowship Program Director Email*

12. Are you a SAGES Member?*

Yes

We invite you to join SAGES now. Membership in the SAGES Active Member tier is required for the certificate. Members also receive discounted registration for the SAGES annual meeting.

13. Year of SAGES Membership:

14. Are you a SAGES Active Member?*

Yes

If you are a SAGES Candidate Member, you can upgrade to Active Membership for a discounted fee of $165. This discount is applied to when you are invoiced for dues during your first year as an Active member. Please note this is only applicable for those upgrading their membership and does not apply to first-time applicants of Active SAGES Membership.

Active Members also receive discounted registration for the SAGES annual meeting.

15. Year of conversion to Active SAGES membership

Payment

Total Due on Submission

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Authorization for Release of Information

Authorization*

By checking this box, I authorize the Fellowship Council and the above named Fellowship Program(s) to share confidential information only as relevant to this application with SAGES. I additionally authorize SAGES to obtain confidential information only as relevant to this application from the Fellowship Council and the above named Fellowship Program(s) and hold these parties harmless for any damages resulting from this exchange of information.

Comments

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