Membership Application International Member: INFORMATION (please print)
Content
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
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Cardholder Cardholder Name
Card #
Exp. Date
Signature
/
Date
Submit
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OR Fax: 847/228-7035
