Resident or Fellow Membership Application

New Resident or Fellow Members

Upon completion of your pediatric residency training, or fellowship, you must request an elevation to active members status by contacting the Texas Pediatric Society in Austin.

Membership *

Resident/Fellow - $ 20.00

Total Amount

Please enter a Username to create an account. If you already have an account please login before completing this form.

Username *

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Punctuation is not allowed in a Username with the exception of periods, hyphens and underscores.

Resident and Membership Profile for Application

Resident or Fellow *

Resident Fellow

First Name *

Last Name *

First and last name will be shared with other visitors to the site.

Middle Name

If you have a different preferred first name, please let us know what you want to go by here.

Medical Credential *

Additional Medical Credentials

MBA, MPH, etc. applies here. Please type in all CAPS, and no periods.

Nick Name *

If you do not have a Nick name you prefer to go by, please re-type your first name. Thank you.

Birth Date *

Residency Program *

Program Address *

Program Address 2

Program City *

Program State *

Program Zip *

Office Phone

Email *

Gender *

Female Male Prefer not to answer

Home Address *

Phone-Mobile (Primary) *

Home City *

State (Home) *

Home Zip *

Medical School *

Internship Start Date

If an exact date is unknown, please choose any day in the closest month and year.

Internship End Date

If an exact date is unknown, please choose any day in the closest month and year.

Fellowship/Specialty

Ethnicity/Race

This information will remain confidential and will be used to serve members.

Credit Card

Card Type

Card Number *

Security Code *

Expiration Date *

My billing address is the same as above

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

State/Province *

Postal Code *

Resident or Fellow Membership Application

Membership Information

Annual Meeting

Preceptorship Program

TPS Foundation

Resources

About TPS