Online Membership Application

Instructions: If you are a current SPA member please include your SPA membership number in the space indicated below. You may also join SPA now by filling out the appropriate portions of this form. If you have any questions or concerns, contact Greg Leasure at 804-565-6305 or via email at greg@societyhq.com.

 

PERSONAL INFORMATION
   
Name (First/Last): 
Degree: 
MD PhD
DO Other (specify)
Date of Birth:(MM/DD/YYYY) 
/ /
   
CONTACT INFORMATION
   
Mailing Address: 
City: 
State: 
Zip/Postal Code: 
Country: 
Cell Phone: 
Office Phone: 
Fax: 
Email: 
   
Hospital Affiliation:
Academic Degrees and other Professional Certification with dates:
   /  / 
  /  / 
  /  / 
Type of Practice:  
Private University Government
Other  
   
MEMBERSHIP CATEGORY
 

I hereby make application for CCAS or joint SPA/CCAS membership:

CLICK HERE FOR DESCRIPTION OF MEMBERSHIP CLASSIFICATIONS

Active Joint CCAS/SPA Membership $450
Active Joint CCAS/SPA/SPPM Membership $600
Affiliate A Joint CCAS/SPA Membership $450
Affiliate B CCAS Only Membership $100
Fellow $100
Resident $0 (complimentary)
International Trainee $15
Medical Student $0 (complimentary)
International Joint CCAS/SPA/SPPM Membership - Tier 1 $75
International Joint CCAS/SPA/SPPM Membership - Tier 2 $48
International Joint CCAS/SPA/SPPM Membership - Tier 3 $24
International Joint CCAS/SPA/SPPM Membership - Tier 4 $9
Please refer to the SPA Website to determine your tier for international membership.

Already a SPA member?

SPA Membership #:

   
PAYMENT OPTIONS
   
Credit Card Type: 
VISA MasterCard AMEX Discover
Card Number: 
Card Holder Name: 
Card Address: 
Card Zip Code: 
Security Code: 
Expiration date: 
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Congenital Cardiac Anesthesia Society
2209 Dickens Rd • Richmond, VA 23230-2005
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E-mail: ccas@societyhq.com
804-565-6305