SPUC Membership Application

The Society is open to all healthcare providers and administratorswho 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 (select all that apply):*

Date of Birth:

/ / (mm/dd/yy)

Hospital/Institution/Practice:*

Academic/Departmental Title:*

Preferred Mailing Address:*

Billing Address:
Check this box if billing address and mailing address are the same.

Mobile Phone:*

Work Phone:

Ext.

Fax:

Email:*

Secondary Email:

MEMBERSHIP TYPE

Founders Circle
$500: Any SPUC member in the Provider or Clinical Administrator categories may join the Founders Circle, established by the Board of Directors. This category is for those with a special interest in supporting the growth of SPUC. Founders Circle members will be recognized on the SPUC website, in certain SPUC publications, and at SPUC's annual meeting. A portion of the Founders Circle membership fee will be allocated for the Michael Moran Scholar Award

Provider
$200: Licensed providers (MD, DO, NP, PA, RN) with an interest in pediatric urgent care. Provider members have voting privileges and may hold office.

International
$200: Licensed providers (MD, DO, NP, PA, RN) or clinical healthcare administrator with an interest in pediatric urgent care. International members have voting privileges and may hold office.

Clinical Administrator
$200: Any person (MD, DO, NP, PA, RN, healthcare administrator, educator), particularly those in an urgent care leadership position, who does not do patient care. Clinical Administrator members do not have voting privileges and do not hold office.

Allied Health
$150: Anyone with an interest in the field of pediatric urgent care (RN, LPN, MA, RRT, PharmD, medic) 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. Trainee members are not eligible to vote or hold office.

Trainee Institution:

(required for trainees only)

Trainee Location:

(required for trainees only)

Date of Graduation:

/ / (mm/dd/yy)

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 fewer 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. If you wish to be on a group bill with your institution, please do not fill out this application. All new group bill members will need to go through your groups' administrator to be added to an existing group bill. Contact Greg Leasure, Membership Manager, at greg@societyhq.com or 804-565-6393.

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: