AAP Council/Section Affiliate Application

** Please Note: All Section/Council Affiliate applications must go through an approval process and have additional documentation required (eg: copy of medical license/CV or letter of recommendation). There is a place to attach documents below.

INFORMATION

First Name *

Middle

Last *

Designation *

MD

DO

Other Other

Gender *

Male

Female

Date of Birth (MM/DD/YYYY) *

Office/Organization Name *

Title

Office Street Address *

Street Address Line 2

City *

State

Zip/Postal Code *

Country *

Office Phone *

Office Fax

Primary Email Address *

Primary Email Type *

Office

Other

Home Street Address

Street Address Line 2

City

State

Zip/Postal Code

Country

Home Phone

Cellular Telephone

Preferred Address *

Office

Home

Preferred Phone

Office

Home

Cell

I AM APPLYING FOR COUNCIL/SECTION AFFILIATE MEMBERSHIP IN... (*=Council) *

LICENSE

States licensed in:

License #

Please provide copy of license (if applicable)

BOARD/PROFESSIONAL CERTIFICATION (if applicable)

Board/Certifying Organization

Certification Date (MM/DD/YY)

Sub-Board

Certification Date (MM/DD/YY)

Please provide copy(ies) of certificate(s).

MILITARY SERVICE

If you are or were in the Uniformed Services, please indicate which branch:

What is/was your rank?

Are you in the reserves?

Yes

No

Are you retired?

Yes

No

GRADUATE MEDICAL EDUCATION (if applicable)

A. Type

Institution

Location

From (MM/DD/YY)

To (MM/DD/YY)

B. Type

Institution

Location

From (MM/DD/YY)

To (MM/DD/YY)

TIME SPENT IN FIELD

Report percent of time spent in field related to the council/section for which you are applying. Describe time devoted exclusively to pediatrics within specialty, i.e., number of hours in clinic, teaching, research, private practice, etc.

	Activity	% Of Time
1	Activity	% Of Time
2	Activity	% Of Time

DOCUMENT UPLOADS

Please upload any additional documents required by the section for which you are applying (eg: letter of recommendation, curriculum vitae, medical license, etc). Section criteria/requirements can be found here.

I have submitted the additional documentation required for approval by the section or council for which I am applying. (Click here for a list of sections and councils and then click the name to go to the criteria page of that section or council). If you answered "no", your application will not be processed until the documentation is received. *

Yes

No

APPLICANT SIGNATURE

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 (please type full name in box) *

Date (MM/DD/YYYY) * +

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 pactice, 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.

**PLEASE NOTE: Applications will not be processed unless the payment section is filled out.

Credit Card Type

Name on Card

Billing Zip code:

Credit Card Number

Expiration Date (mm/yy)

CVV:

Electronic Signature (type name in box):

Date (MM/DD/YYYY) +

PLEASE NOTE: All council/section affiliate applications go through an approval process. Your credit card will not be charged until approval is granted and your council/section membership is active. You will receive a confirmation email with a receipt at that time.

Administration & Practice Management ($75)	Administration & Practice Management - Consultant ($340)	Adolescent Health ($125)
Advances in Therapeutics & Technology ($40)	Anesthesiology & Pain Medicine ($60)	Bioethics ($60)
Cardiology and Cardiac Surgery ($60)	Child Abuse and Neglect ($60)	Child Death Review and Prevention ($60)
Children and Disasters* ($60)	Children with Disabilities* ($50)	Clinical Information Technology* ($60)
Clinical Pharmacology & Therapeutics ($60)	Communications & Media* ($60)	Community Pediatrics ($60)
Critical Care ($30)	Dermatology ($60)	Developmental & Behavioral Pediatrics ($60)
Early Childhood* ($60)	Emergency Medicine ($60)	Endocrinology ($60)
Epidemiology, Public Health & Evidence ($60)	Foster Care, Adoption & Kinship Care* ($60)	Genetics* ($60)
Global Health ($20)	Hematology/Oncology ($60)	Home Care ($60)
Home Care - Family Member ($0)	Hospice & Palliative Medicine ($25)	Hospice & Palliative Medicine - Parent ($0)
Hospital Medicine ($60)	Infectious Diseases ($60)	Injury, Violence & Poison Prevention* ($60)
Integrative Medicine ($60)	LGBT Health & Wellness ($45)	Minority Health, Equity, and Inclusion ($60)
Neonatal-Perinatal Medicine ($60)	Neonatal-Perinatal Medicine - Physician ($85)	Nicotine & Tobacco Prevention and Treatment ($20)
Obesity ($30)	Ophthalmology ($30)	Oral Health ($60)
Orthopaedics ($60)	Otolaryngology, Head & Neck Surgery ($60)	Pediatric Pulmonology & Sleep Medicine ($60)
Plastic Surgery ($60)	Quality Improvement & Patient Safety- Pro ($50)	Quality Improvement & Patient Safety- Non-pro ($0)
Radiology ($60)	Rheumatology ($60)	School Health* ($60)
Simulation & Innovative Learning Methods ($20)	Sports Medicine & Fitness* ($60)	Surgery ($60)
Telehealth Care ($60)	Transport Medicine ($60)	Uniformed Services ($60)
Urgent Care Medicine ($20)	Urology ($60)