Membership Application and Renewal Form

Member Type

*If you are a TPS member in your first year post-residency, please contact the TPS Director of Member Services Crystal Healey via email at crystal.healey@txpeds.org at (512) 370-1517.

Membership *

Active - $ 220.00

Resident/Fellow - $ 20.00

Student - $ 15.00

Associate - $ 220.00

Additional Contribution *

TPS Foundation Donation - $ 100.00

No thank you

Other Amount

Total Amount

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

Username *

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

Membership Profile for Active Member Type

First Name *

Middle Name

Nickname

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

Last Name *

Individual Suffix

Medical Credential

In the next field, enter any additional academic accreditations. Such as: MPH, MBA, PhD, FAAP, etc. Please type in all CAPS, and no periods.

Additional Credentials

TX Medical License Number *

Preferred Email *

Secondary Email

Current Employer *

Job Title

Office Address *

Office Suite Number

Office Zip *

Office City *

Office State *

Office/Practice Website

Home City *

Home Address *

Home State *

Home Zip *

Preferred Address *

Office Home

Phone-Mobile (Primary)

Office Phone Number *

Fax Number

Preferred Communication Method

Phone
Email
Opt-in for Texts

Primary Employment Setting

Primary Practice Location

We appreciate this information in order to help us better serve our members.

Primary Board Name *

Medical School End Date

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

Medical School

Residency Program *

Fellowship

Birth Date *

License Year

Residency End Date

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

Fellowship End Date

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

Sub-Specialty Board

Ethnicity/Race

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

Languages

Gender *

Female Male Prefer not to answer

Military Service

How did you hear about TPS

Membership Application and Renewal Form

Membership Information

Annual Meeting

Preceptorship Program

TPS Foundation

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Membership Information

Annual Meeting

Preceptorship Program

TPS Foundation

Resources

About TPS