Society of Professors of Child and Adolescent Psychiatry

Membership Application

Membership in the SPCAP is restricted to child and adolescents psychiatrists who are division, section or free-standing department directors of child and adolescent psychiatry within or affiliated with an accredited medical school in the U.S. or Canada. Any individual who ceases to be a director shall cease to be an Active member. If an individual has had a cumulative five years as a Member, he or she may request a transfer to Emeritus Member status.

Please include a letter from the Chair of the Department of Psychiatry or Dean of the School of Medicine verifying your directorship of the program (a template has been provided for your convenience). Dues are $175.00 for the calendar year. Complete and mail this form with check to:

NAME:

TITLE:

INSTITUTION:

MAILING ADDRESS:

CITY, STATE, ZIP

EMAIL ADDRESS:

PHONE NUMBER:

FAX NUMBER:

Please check all that apply to your position in your division:

¨ Active SPCAP Member

¨ Emeritus SPCAP Member

¨ Division Director

¨ Residency Training Director

PAYMENT TYPE:		¨ Check (payable to SPCAP))	¨ Credit Card
Credit Card Type:	¨ Visa ¨ MasterCard				$ _______
Credit Card #				Exp. Date: __________
Name on Card:
Signature:

Please mail this form with payment to: Earl Magee, SPCAP Administrator, SPCAP, 3615 Wisconsin Avenue, NW, Washington, DC 20016 and a letter of verification with this application.

Thank you!