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* 1. First Name

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* 2. Middle/Maiden

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* 3. Last Name:

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* 4. MD, DO, or Other (Specify)

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* 5. Gender

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* 6. Institution/Organization Name (if applicable)

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* 7. Preferred Address & Phone

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* 8. Number/Street/Suite

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* 9. City/State/Zip or Postal Code/Country

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* 10. Phone

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* 11. Email Address

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* 12. Fax

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* 13. Please indicate your training:

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* 14. Categories of Chapter Membership: (Please Check ONE): 

• Fellow: Applicants must have received initial board certification in pediatrics from an approved Board.

• Specialty Fellow: Applicants must be certified by Boards other than the Boards that qualify them for Fellow and meet the requirements as determined by the specialty section through which they apply.

• Emeritus/ Retired Fellow: Applicant who is no longer practicing but is still interested in having access to the benefits of membership. Will not accrue CME credits.

• Associate Member: Physician/Dentist who has not completed training in a pediatric or surgical residency that is approved for credit toward certification by an eligible Board.

• Candidate Member: Completed training in a pediatric or surgical residency that is approved for credit toward certification by an eligible Board.

• Post-Residency Training Member: Fellowship trainees in a pediatric subspecialty or surgical fellowship training program.

• Resident Member: Currently enrolled in an approved pediatric residency program.

• National Affiliate: Physician’s Assistant or Nurse Practitioner who is a member of both the national and chapter AAP.

• Physician/Dentist Chapter Affiliate: Physicians/Dentists who are chapter members but not national members.

• Chapter Affiliate: (Allied Health, Nurse, Parent/Family, Professional Staff, Non-health Care).

• Chapter Affiliate Student: Available to students enrolled in an accredited medical or other graduate health professional school.

(Please Check ONE)

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