Membership Application

Thank you for recognizing the importance of supporting your local pediatrics community and applying for membership in the North Pacific Pediatric Society. Your participation and financial support is essential as we continually strive to strengthen our organization.

Contact Information

Name:
Title:
Practice/Group Name:
Practice Address:
Practice Phone:
-
Practice E-mail:
Hospital Affiliation:
Home Address:
Home Phone:
-
Home E-mail:
Preferred Address for NPPS Correspondence:

Education

(School name/location & years attended)


Premedical Education:
Medical School:
Residency:
Fellowship:
Date of Board Certification:
Board Eligible:
Professional Society Memberships:

Membership Dues

Active membership
Open to any medical or osteopathic physician in good standing whose practice is limited to pediatrics, and who promotes or otherwise supports the purposes of the Society. Active members shall be required to pay dues and shall be entitled to vote and hold office.

Associate membership
Open to any medical or osteopathic physician in good standing whose practice is especially interested in pediatrics, but not necessarily confined to pediatrics, and who promotes or otherwise supports the purposes of the Society. Associate members shall be required to pay dues and shall be entitled to vote and to hold office.

Affiliate membership
Open to any Medex or Nurse Practitioner whose practice has a significant focus in pediatrics, but not necessarily confined to pediatrics, and who promotes or otherwise supports the purposes of the Society. Affiliate members shall be required to pay dues and shall be entitled to vote, but shall not be entitled to hold office.

Membership Dues - $100:*
Total:
Please verify:

Upon completing the form and clicking "submit," you will be directed to PayPal to make the membership dues payment.



INQUIRIES
Contact Darla White, Association Executive, at the NPPS office at 206-956-3642 or email ddw@wsma.org