Join the Louisiana Chapter Today Chapter Member Application Step 1 of 4 25% Contact InformationName(Required) First Last Credentials(Required) MD DO Other Specialty Preferred Address & Phone Home Office Organization or Group Practice Name (if applicable): Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)MobileEmail(Required) FaxOffice/Practice Manager First Last MembershipMembership Categories Fellow – $200 – Fellow, American Academy of Pediatrics residing in Louisiana Specialty Fellow – $200 – Fellow, American Academy of Pediatrics residing in Louisiana with a specialty other than general pediatrics Chapter Affiliate – $200 – Any physician who resides in Louisiana who is engaged primarily in pediatric practice, teaching or research and is not already a Fellow of the AAP Associate Member – $100 – Pediatric Dentist residing in Louisiana who has received a certificate or a degree in the specialty of pediatric dentistry from a program accredited by the Council on Accreditation of the American Dental Association and practices pediatric dentistry in the United States, Puerto Rico, or Canada National Affiliate Members of the AAP – $100 -either (a) a licensed Physician Assistant who has received a certificate from an ARC-PA accredited program, practices in the United States, Puerto Rico, or Canada, and is working in a pediatric setting or at least 50% of professional activities is with infants, children, adolescents, or young adults. A copy of the certificate and one sponsor statement from an FAAP in good standing is required. or (b) a pediatric nurse practitioner licensed and certified in the United States, Puerto Rico, or Canada, working as a member of a pediatric care or medical home team. A copy of the certificate and one sponsor statement by a FAAP in good standing are required. Candidate Member – $50 – Limited to a 4 year period post-residency training for pediatricians who are members of the AAP Post-Residency Training Member – $50 – AAP members who are in fellowship training Resident Member – $0 – Pediatric residents who belong to the AAP Medical Student Member – $0 – medical students in Louisiana Senior Fellow – $0 – Fellow, American Academy of Pediatrics and has attained the age of 70 OR Fellow, American Academy of Pediatrics who is 65 or older and no longer derives income from professional activities. Senior Member – $0 – Any pediatric physician who lives in Louisiana and has attained the age of 70 OR any pediatric physician who lives in Louisiana, is 65 or older, and no longer derives income from professional activities.Membership Category(Required)MembershipFellowSpecialty FellowChapter AffiliateAssociate MemberNational Affiliate Members of the AAPCandidate MemberPost Residency Training MemberResident MemberSenior FellowSenior Member EducationCollege(Required) Degree(Required) Graduation Date(Required) Medical School(Required) Degree(Required) Graduation Date(Required) Internship(Required) Dates(Required) Residency(Required) Dates(Required) Fellowship Dates Signature(Required) I certify that all of the information in this application is true. PaymentPayment type(Required) Check Credit Card Total Δ
