SPUC Membership Application

Membership Advantages:

Reduced fees at Annual Meetings
Opportunity to network with physicians and administrators across the nation
Online Discussion group
Access to Clinical Guidelines for Pediatric Urgent Care
Access to Business Data/Quality Metrics/Organizational Information
Pediatric Urgent Care educational materials and research
Committee participation

The Society is open to all healthcare providers and administrators, who are actively involved in the delivery of pediatric urgent care, and to all those who wish to advance the society’s mission on an institutional, local, national and international level.

CONTACT INFORMATION

First Name:

Last Name:

Middle Initial:

Degree:

Specialty:

Date of Birth:

/ / (mm/dd/yy)

Affiliation:

Preferred Mailing Address:

Billing Address:
Check this box if Billing Address and Mailing Address are the same.

Home Phone:

Work Phone:

Ext.

Fax:

Email:

Secondary Email:

MEMBERSHIP TYPE

Founders Circle
$500: Any healthcare provider who meets the Provider or Clinical Administrator categories may join by paying the fee established by the Board of Directors.

Provider
$200: Licensed providers (MDs, DO, NPs, PAs) with an interest in pediatric urgent care. Provider members have voting privileges and may hold office.

Clinical Administrator
$150: Any RN (particularly those in leadership positions), healthcare administrator, or educator who is not a physician or a physician in training. Clinical Administrator members have voting privileges and may hold office.

International Category
$200: Licensed providers (MDs, DOs, NPs, Pas, RN) or clinical healthcare administrator with an interest in pediatric urgent care. International members will have voting privileges and may hold office.

Allied Health
$200: Anyone with an interest in the field of pediatric urgent care who does not meet the criteria of any other category may become an Allied Health member. Allied Health members are not eligible to vote or hold office.

Trainee
$50: Any student, resident or healthcare provider involved in a training program may become a member. Trainee members are not eligible to vote or hold office.

Trainee Institution:

(required for trainees only)

Location:

(required for trainees only)

Date of Graduation:

/ / (required for trainees only)

GROUP BILLING

Group Billing — 10% or 15% Discount on Dues. Receive a 10% discount on member dues in the group billing program for groups of 34 members or less for your practice or institution. Groups of 35 or more members will receive a 15% discount. The Society will send one comprehensive renewal notice to include all the SPUC members in your practice or institution. Contact Greg Leasure, Membership Manager, at greg@societyhq.com or 804-565-6393.

MEMBER REFERRAL

I was referred by: (if any)

PAYMENT OPTIONS

Promo Code
If you are supplying a promo code, please make sure you have selected a membership type and verify your promo code by selecting the "Verify Code" button before submitting your application.

Promo Code:

Card Number:

Security Code:

Expiration Date:

Card Address:

Card Zip Code:

Name printed on card: