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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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip/Postal Code
*
Country
*
USA
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Rep
Chad
Chile
China
Colombia
Comoros
Congo
Congo (Democratic Rep)
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland (Republic)
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar, (Burma)
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
St Kitts & Nevis
St Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Office Phone
*
Office Fax
Primary Email Address
*
Primary Email Type
*
Office
Other
Home Street Address
Street Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip/Postal Code
Country
USA
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Rep
Chad
Chile
China
Colombia
Comoros
Congo
Congo (Democratic Rep)
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland (Republic)
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar, (Burma)
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
St Kitts & Nevis
St Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Home Phone
Cellular Telephone
Preferred Address
*
Office
Home
Preferred Phone
Office
Home
Cell
I AM APPLYING FOR COUNCIL/SECTION AFFILIATE MEMBERSHIP IN... (*=Council)
*
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)
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:
Army
Navy
Air Force
Public Health Service
N/A
What is/was your rank?
1st Lt
2nd Lt
ADM
Brig Gen
Capt.
CDR
Col.
ENS
FADM
Gen
LCDR
LT
Lt Col
Lt Gen
Maj Gen
Maj.
RADM
VADM
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
Visa
MasterCard
American Express
Discover
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.