Final Program - American Academy for Cerebral Palsy and ...

Please TyPe or PrinT Clearly
DATE SUBMITTED:
2008 AACPDM Membership Application
Name
(First/Given) (Middle) (Last/Family) Degree
Date of Birth Birthplace Citizenship
City State/Province Country
Specialty Diplomat Yes No
remiT To aaCPdm offiCe:
555 E . Wells St ., Suite 00
Milwaukee, WI 53202-3823
+ (4 4) 9 8-30 4
Fax: + (4 4) 276-2 46
Types of Membership:
Fellow - Must have a minimum of a Bachelor’s Degree .
International Corresponding - Must reside outside of the United States and Canada .
Trainee/Student/Resident - Professional attending post-entry professional training . This membership category is good for two years . After two years, you
will automatically become a Fellow member .
Curriculum vitae must accompany all applications
Professional address
Institution (if any)
Street
City State / Province Country Postal Code
Telephone Fax E-mail
Home address
Street
City State / Province Country Postal Code
Telephone Fax E-mail
Specify address to which AACPDM correspondence is to be directed: Professional Home
name of sPonsor
Having a sponsor is no longer required; however, if a member of AACPDM recommended that you join, please print their name here:
Undergraduate education Degree Year
Graduate education, including professional school Degree Year
Other post-graduate study, including fellowships and residencies