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Membership Application International Member: INFORMATION (please print)

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Membership Application • • International Member

FOR AAP USE ONLY   AAP ID#_________________________

If you have previously been a member of the AAP, please call 800-433-9016.

DIST___________ DIST___ ______________ _____________ ___________ _____

INFORMATION  (please print) First Name o

 MD

  o

 DO

Middle/Maiden   o

 

 Other (specify)

o

Office Address & Phone o  Check

  o

 Female

  Date of Birth / (MM/DD/YY / )

Home Address & Phone

if this is preferred mailing address

 

Organization Name

o  Check

if this is preferred mailing address

Number/Street/Suite  

Title

 Male

Last

City/State

Number/Street/Suite

Zip/Postal Code/Country

City/State

Telephone

Zip/Postal Code/Country

o  Preferred

contact number 

o  Preferred

contact number 

o  Preferred

email address

Cellular Telephone o  Preferred

contact number 

Telephone

 

Home Email o  Preferred

Business Email *Applicants must provide a valid e-mail address.

email address

QUALIFICATION  (REQUIRED INFORMATION) Local IPA Society where you are a member  OR

Full Name of Society

Country

Sponsor Signature

Date

Print Name

AAP ID#

MEDICAL EDUCATION AND RESIDENCY  Medical Medic al Education Education Graduation Date ______ ______ /______ /______ /______

 A

B

Type of Residency

Type of Residency

Institution

Institution

Location

Location

/

/

From (MM/DD/YY)

/

/

To (MM/DD/YY)

/

/

From (MM/DD/YY)

/

/

To (MM/DD/YY)

FELLOWSHIP TRAINING  A

B

Type of Fellowship

Type of Fellowship

Institution

Institution

Location

/

Location

/

From (MM/DD/YY)

/ To (MM/DD/YY)

/

/

/

From (MM/DD/YY)

/ To (MM/DD/YY)

• • • • • •   CONTINUED

/

 

BOARD CERTIFICATION  A  Pediatric Board

 

/

/

 

Certification Date (MM/DD/YY)

B

 

Subspecialty Board

/

/

Certification Date (MM/DD/YY)

DEMOGRAPHIC INFORMATION This information will remain confidential and will be used to serve members. Indicate your primary employment During a typical work week, in which professional activities do you spend your  setting: o Pediatric Group Practice time? o Multi-specialty Group Practice o Direct Patient Care o Solo/Two-Physician Practice o  Admin  Administrat istration ion o  Acade  Academic mic Institution Institution (i.e. medical o  Acade  Academic mic Medicine Medicine o Research school) o o

Hospital/Clinic Non-practice Industry o Non-practice Government

In these activities combined, do you: o Work less than 40 hours/week o Work 40 hour/week or more o Currently not in practice

Indicate your specialty: o General Pediatrics Pediatrics o Specialty

Describe your primary practice location: o Urban, inner city o Urban, non-inner city o Suburban o Rural Ethnicity/Race o Black/African American o  Asian o Pacific Islander  o Hispanic/Latino o Native American or Alaskan Native o White/Caucasian o Middle Eastern o Indian o Other 

 JOIN A SECTION/COUNCIL Please indicate with an X if you would like to join any of the following sections/councils (note: Sections/cou Sections/council ncilss have dues in addition to the national dues and may have specific require requirement ments. s. Please Please visit www.aap.org/members/seccriteria.htm): o   Advances in Therapeutics & o   Complementary & Integrative o   Hospice & Palliative Medicine ($25) Technology (Provisional) ($0) Medicine ($25) o   Injury, Violence & Poison Prevention o   Anesthesiology & Pain Medicine ($0) o   Critical Care ($35) ($15) o   Bioethics ($25) o   Developmental & Behavioral o   International Child Health ($40) o   Breastfeeding ($35) Pediatrics ($35) o   Obesity ($0) o   Cardiology & Cardiac Surgery ($30) o   Early Education o   Ophthalmology ($25) Education & Chil Child d Care ($30) ($30) o  Child Abuse & Neglect ($40) o   Emergency Medicine ($40) o   Rheumatology ($40) o   Children with Disabilities ($25) o   Foster Care, Adoption Adoption and Kinship o   Sports Medic Medicine ine & Fitne Fitness ss ($20) o  Communications & Media ($25) o   Telehealth Care ($25) Care ($30) o   Community Pediatrics ($30) o   Hospital Medicine ($30) o   Transport Medicine ($0)

 APPLICANT SIGNATUR ATURE E  APPLICANT SIGN I hereby certify that all information recorded on this application and any attached documents are accurate and support my qualifications for membership in the Academy for which I now apply. Signature of Applicant Date If the Academy learns that any information in your application is untrue, or if circumstances change after the date of application that affect ethical and professional standards, it may be grounds for suspension or revocation of membership. The American Academy of  Pediatrics does not adopt any practice, policy, or procedure which would result in discrimination on the basis of race, religion, creed or  health status for membership. Cancellation of membership must be submitted in writing and cannot be granted retroactively.

PAYMENT  — To pay your 12 month dues payment, please complete below. Inte Intern rnat atio iona nall Memb Member ersh ship ip — Pl Plea ease se vi visi sitt www. www.aa aap. p.or org/ g/me memb mber er/i /int nter erna nati tion onal alre req. q.ht htm m for for pr pric icin ing. g. Section/Council  (Name)  

$ $

To join a section/council visit www.aap.org/member/seccriteria.htm and then list the name(s) above with dues amount.

Total   $ 0.00 My check for $ is enclosed — Check #   o I will pay using the following credit card:   o  Visa   o Mastercard o

 Amountt $  Amoun

(Make check payable to: American Academy of Pediatrics)   o  Amer Express Express   o

Discover 

Cardholder Cardholder Name

Card #

Exp. Date

Signature

/

Date

Submit

 

Reset

OR Fax: 847/228-7035

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