Society for Pediatric Dermatology: Membership Application

Contact Information

First Name:

Last Name:

Credentials:

Email:

Office or Mobile Number:

Fax:

Birthday:

Login Information

Username: Must be at least 8 characters long.

Password: Password is case-sensitive. Must be at least 8 characters long.

Confirm Password:

Preferred Mailing Address

The address to receive the journal, newsletter, and annual meeting information.

Country:

Address 1:

Address 2:

City:

State/Province:

Postal Code:

Patient Access Information

Appears in “Find a Pediatric Dermatologist” search results.

Would you like to appear in the “Find a Pediatric Dermatologist” search results?

Use the Preferred Mailing Address & Telephone

Country:

Address 1:

Address 2:

City:

State/Province:

Postal Code:

Telephone:

Subspecialty interests or areas of expertise:

Website:

Education and Professional Affiliations

Enter NA if it does not apply to you.

Medical School:

Years:

Internship:

Years:

Residencies:

Years:

Fellowships:

Years:

Specialty Boards

Appears in “Find a Pediatric Dermatologist” search results. Please use the following abbreviations where applicable:

ABD – American Board of Dermatology
ABP – American Board of Pediatrics

Dermatology:

Certification Year:

Pediatrics:

Certification Year:

Other:

Certification Year:

Current Hospital Affiliations

Hospital:

Position:

Hospital:

Position:

Current Medical School Affiliations

School:

Position:

School:

Position:

Training Program Verification

Residents & Fellows: All applicants must supply a verification letter from their Program Chair confirming their current status in a training program. This also applies to medical students applying for SPD membership at the Resident/Fellow level.

To expedite the application process, we suggest that Resident & Fellow applicants select the “Check here to request a verification letter by email” box to the right.

Verification letters to support your application should be:

emailed to info@pedsderm.net
faxed to 317-205-9481
or mailed to:

SPD
8365 Keystone Crossing
Suite 107
Indianapolis, IN 46240

Check here to request a verification letter by email. An automated email will be sent to your Program Chair asking them to provide a verification letter by email. This may expedite completion of your application.

Program Chair

Name:

Program Affiliation:

Email:

Member Profile

Please choose a description from the list below that best describes you.

I am actively practicing teledermatology

Initiation and First Year Membership Fee

All fees are payable in US funds drawn on a US bank.

Practicing Physicians in developing countries must have written committee approval.

The membership fee covers an initiation fee of $100.00, the first year's dues of $70.00, and the rest is the yearly subscription rate for Pediatric Dermatology, SPD’s Journal. For physicians outside the U.S., the increased fee is to cover the cost of additional postage.

Research Surveys

SPD supports the collection of adequate data from members to help facilitate important research in pediatric dermatology. To assist that objective, the SPD circulates electronic surveys from time to time as a form of research collaboration. These surveys are reviewed and approved by the SPD’s Research Committee prior to distribution. All members receive these electronic surveys by default, however if you would like to opt out, please select “No” in the drop down menu below.

I would like to receive SPD-approved research surveys:

Note: Opting out of receiving SPD-approved research surveys will not prevent you from receiving other emails from the SPD.

PeDRA Membership Dues

Yes, I would like to join the Pediatric Dermatology Research Alliance (PeDRA) at this time.

PeDRA Membership Dues:

Note: If you choose this option, you will see separate credit card charges for SPD and PeDRA membership.

Questions about your PeDRA Membership? Please email PeDRA at info@pedraresearch.org.

Pediatric Dermatology Journal

How Do You Prefer to Receive It?

SPD is going green through increased online distribution of research and educational materials, including our flagship journal Pediatric Dermatology. If you wish to opt out of receiving a printed journal, please select “Online Access Only” below.

If you are a resident/fellow/medical student and wish to receive a print copy of the journal mailed to you, there is an additional $95 fee. Please select “Print & Online Access” from the drop down menu below if you would like this option. Online only access is provided at no additional cost with your free membership.

Payment Information

Promo Code:

Credit Card:

Card Number:

Expiration Date:
/

Card Verification:
3 or 4 digit verification code on card

First Name:

Last Name:

Billing Information

Please enter the billing information that is on record for this credit card.

If it is the same as above, please check the box and leave these fields empty.

Use my Preferred Mailing Address

Country:

Address:

City:

State/Province:

Postal Code:

Telephone:

When you click Review you will be presented with a review of your information along with the total amount to be charged.
Your application will not be complete until you click Submit on the next page.

Membership Application

Contact Information

Login Information

Preferred Mailing Address

Patient Access Information

Education and Professional Affiliations

Specialty Boards

Current Hospital Affiliations

Current Medical School Affiliations

Training Program Verification

Program Chair

Member Profile

Initiation and First Year Membership Fee

Research Surveys

PeDRA Membership Dues

Pediatric Dermatology Journal

Payment Information

Billing Information

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