| Is this for 2012? (y or n) |
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| Is this for a different year? If so enter
the year
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| Membership Status (if you are unsure, please view
membership policy and/or comment
in note at bottom) |
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From the choices at right, please enter the $ amount you are going to pay,
e.g. 295
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-Active (Voting): US Dues $295
-Active (Voting): International $350
-Associate (Non-voting): House Officer $20
-Associate (Non-voting):
-Coordinator/Administrator $20 |
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| Last Name |
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| First Name |
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| Title (MD, PhD, Ed.D. etc) |
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| Institution Name: |
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| Street Address |
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| Address (cont) |
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| Phone (e.g.. 223-446-5000) |
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| Fax (e.g.. 223-446-5000) |
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| Email |
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| City/Province |
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| State |
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| Zip |
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| Medical School Affiliation (if different than institution): |
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| Current position (please check as many as apply) |
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Lecturer in Human Behavior, Psychopathology, or Clerkship
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Clinical Attending for Psychiatry Clerkship |
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Director or Site Coordinator, Clerkship in Psychiatry |
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Director, Psychopathology or equivalent course |
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Director, Human Behavior, Interviewing or equivalent course |
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Asst or Assoc Director, Medical Student Education |
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Director, Medical Student Education
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Director or Vice-Chair, Psychiatry Education |
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Chair, Dept of Psychiatry |
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Other (fill in the blank) |
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| Please check the groups to which you belong currently as a member
of: |
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AADPRT |
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AAP |
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AACDP |
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AACAP |
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| Please let us know the names of the guest(s) you will be
bringing to the meeting (separate by comma; meal charges
apply, as per next screen): |
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| Please specify the # of persons (you and/or guests) wanting vegetarian
lunch/dinners
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| Please specify the # of persons (you and/or guests) wanting
gluten-free meal |
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| Note (optional):
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Please do not click "submit" until you have completed
the form in full. After clicking submit, you will
be shown a confirmation screen. If you see a mistake, simply click
"back" in your browser to make the correction (do not worry, the form will remember all entries and
you will NOT have to reenter everything).
You will be able to go to the next step, meeting fee details.
Questions?
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