Enterprise Membership Interest Form

AAP Enterprise Membership (EM) is a multi-year collaboration with AAP national, your state AAP chapter, and your pediatric organization. For the most accurate cost estimate, please include all member-eligible physicians in your organization. Advanced practice providers are welcome to join as well!

EM offers member benefits and services to the individual and organization. Submit this form with a roster and AAP will contact you shortly. Thank you for your interest.

Organization

Organization Name

Type of Organization or Division

Eg. academic institution, hospital, health system etc.

Organization website

Organization Street Mailing Address

State

Primary Contact Person

Name

Title at Organization

Phone Number

Phone

Contact Preference

Phone

Approximately how many people in your organization are eligible for AAP membership?

This number should include all MDs, DOs, PAs and NPs. Please do not include anyone in training.

To provide a full cost estimate, we require the first and last name, email address and birthdate for each eligible provider in your organization.

Will you be able to provide this information?

Yes, I can provide a roster now.

Yes, I can provide a roster at a later time.

No, I will not be able to provide that information.

Please provide any additional comments.

Send me a copy of my responses

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