Online Membership Application Join SPA Today! I was referred to SPA by:(current SPA member name, if any) Name: M.D. Ph.D. D.O. other (specify) Mailing Address: City: State: Country: Zip Code: Office Phone: Fax: Date of Birth: / / Email address: Hospital Affiliation: ABA ID# "if applicable": Academic Degrees and other Professional Certification, with dates: / / / / / / Type of Practice: Private University Government Other Membership classifications: -- Members that are eligible for SPA Affiliate membership are also eligible for SPPM Affiliate A membership. For more information, visit www.pedspainmedicine.org. -- The International membership categories are tiered based on the World Bank of Economies. Please refer to the SPA Website www.pedsanesthesia.org/international-membership-tiers to determine your tier. Active Members: The active class of member shall consist of physicians who have an interest in pediatric anesthesia and are eligible to be members of the American Society of Anesthesiologists. Affiliate Members: The affiliate class of membership shall consist of physicians who have an interest in pediatric anesthesia and are ineligible to be members of ASA and nonphysicians who have an interest in pediatric anesthesia. Any person classified as an affiliate member shall not have voting privileges and shall be restricted from election to the Society's Board of Directors. International Membership with SPA, CCAS, and SPPM): Physicians practicing outside of the US and Canada who have an interest in pediatric anesthesia, pediatric pain medicine, and congenital heart disease and are eligible to be affiliate members of the ASA. International members will receive membership in the Congenital Cardiac Anesthesia Society, Society for Pediatric Anesthesia, and Society for Pediatric Pain Medicine. Each International Member shall be entitled to one vote on each matter submitted to the membership of the Society for a vote. The tiered dues categories are based on the World Bank of Economies. Please refer to the SPA Website to determine your tier. Active/Affiliate Joint Membership with CCAS: Active and affiliate SPA members qualify for joint membership with the Congenital Cardiac Anesthesia Society. Active/Affiliate A Joint Membership with SPPM: Active and Affiliate SPA members qualify for joint membership with the Society for Pediatric Pain Medicine. Active B Membership with SPPM: The SPPM Active B class of membership shall consist of physicians who practice or have an interest in pediatric pain medicine and are ineligible to be members of the American Society of Anesthesiologists; and psychologists, nurses, physical therapists and other non-physician providers who practice or have an interest in pediatric pain medicine. Any person classified as an SPPM Active B member shall have full SPPM voting privileges and shall be eligible for election to the Society's Board of Directors. Fellow Membership: $100 Physicians performing post residency fellowship training. Fellow members will receive memberships with SPA, CCAS and SPPM. Resident Membership: Complimentary Physicians in an approved residency training program. Resident membership requires endorsement by program director. Resident members will receive memberships with SPA, CCAS and SPPM. International Trainee: $15 Fellows and residents outside of North America. International Trainee members will receive mameberships with SPA, CCAS and SPPM. Medical School Student Membership: Complimentary Students from an accredited medical school who have an interest in pediatric anesthesia, pediatric cardiac anesthesia, or pediatric pain management. Student Members will receive membership with SPA, CCAS, and SPPM. Stembers shall not be entitled to vote on any matters submitted to the membership of SPA, CCAS, SPPM for a vote. I am applying for: Active (Physician) $325 Affiliate (Non-Physician) $325 International Tier 1 SPA/CCAS/SPPM $75 International Tier 2 SPA/CCAS/SPPM $48 International Tier 3 SPA/CCAS/SPPM $24 International Tier 4 SPA/CCAS/SPPM $9 Active SPA/CCAS (Physician) $450 Affiliate SPA/CCAS (Non-Physician) $450 Active SPA/SPPM $475 Affiliate SPA/SPPM $475 Active SPA/CCAS/SPPM $600 Affiliate SPA/CCAS/SPPM $600 Affiliate B CCAS $75 Active B SPPM $100 Affiliate B SPPM $75 Resident SPA/CCAS/SPPM Complimentary Medical Student Complimentary Fellow SPA/CCAS/SPPM $100 International Trainee $15 Medical School: Medical School Completion Date: / / Residency/Fellowship Location: Residency/Fellowship Director: Residency/Fellowship Completion Date: / / Payment: VISA MasterCard AMEX Discover Card Holder: Card No: Card Address: Card ZIP or Postal Code: Card CVV (security code): Exp. Date: 1 2 3 4 5 6 7 8 9 10 11 12 Month Year 20232024202520262027202820292030203120322033 Note: This is a secure transaction system. However, if entering your credit card information online makes you uncomfortable, please pay by check. Send all checks to SPA, 2209 Dickens Road, Richmond, VA 23230-2005