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ADMSEP Membership Application and Payment (all electronic)

Directions:   This is a 3 step process.

Step 1:  Please complete the information below, review then click "submit" at bottom.  You will then be taken to the next step, membership type selection.  Questions?  
Please check the time period you are paying for:      July 2010-June 2011    July 2009-June 2010     July 2008-June 2009    Other:
       
Last Name Institution Name:  
First Name Title (MD, PhD, Ed.D. etc)  
Street Address Phone  (e.g.. 223-446-5000)
Address (cont.) Fax (e.g.. 223-446-5000)
City E-mail
State/Province    
Zip Code    
 

Medical School Affiliation (if different than institution):

  

Current position (check as many as apply)
Lecturer in Human Behavior, Psychopathology, or Clerkship (LHBP)
Clinical Attending for Psychiatry Clerkship (CACP)
Director or Site Coordinator, Clerkship in Psychiatry (DSCP)
Director, Psychopathology or equivalent course (DP)
Director, Human Behavior, Interviewing or equivalent course (DHB)
Asst or Assoc Director, Medical Student Education (ADMSE)
Director, Medical Student Education (DMSE)
Director or Vice-Chair, Psychiatry Education (DPE)
Chair, Department of Psychiatry (CP)
  Other: 

If there are other educators in your department who may benefit from joining ADMSEP, please write the person's name here:   
 

If you are replacing a member of your department WHO WILL NOT be continuing as an ADMSEP member, please write the person's name here:

  
 
Please check if you are also currently a member of:    AADPRT     AAP     AACDP  
   
Note (Optional):  
Important:  Please do not click "submit" until you have completed the form in full and reviewed.  After clicking submit, you will then be taken to the next step, membership type selection.  Questions?  


03/22/10