Air Medical Physician Association

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The Air Medical Physician Association

AMPA Yearly Membership

All membership levels receive the following:

CDROM version of Principles and Direction of Air Medical Transport
Subscription to the Air Medical Journal
Listing in the AMPA Membership Directory
Association Newsletter
Discounted registrations to annual fall Air Medical Transport Conference and annual spring Critical Care Transport Medicine Conference

Membership Form

	Active Member - $ 350.00 physician, voting
	Founding Member - $ 200.00 '92 Snowbird Conference - (physician, voting)
	Academic Membership - $ 300.00 Available to Residency Programs - up to 50 residents
	Affiliate - $ 125.00 Non-physician, non-voting
	Medical Student / Resident - $ 75.00 Documentation required, non-voting

	I will send payment by check or fax
Email Address *

If you would like to create an account on this site, check the box below and enter a user name and a password. If you already have an account, please login before completing this form.

Create an account?

Username	Your preferred username; punctuation is not allowed except for periods, hyphens, and underscores.
Password
Confirm Password	Provide a password for the new account in both fields.

Contact Information

First Name *
Last Name *
Credentials	Professional credentials
Program / Company Name	Please enter your flight program or company name.
Phone *
Fax
Street Address *
Address 1
Address 2
City *
State
Country *
Postal Code *

Membership Survey

Please answer the following questions to help AMPA better serve you:

Is your transport program:

rotor wing

fixed wing

ground

hospital-affiliated

free standing

for profit

not-for-profit

Check all that apply.

Position

Tenure

If you are a Medical Director, how long have you had this position?

Time

How much time weekly do you spend on medical direction?

Specialty

Your medical specialty

CAMTS ?

Yes No
Is your transport program CAMTS accredited?

Motivation

What is your motivation to become an AMPA member or to renew your membership?

Other Activities?

What educational (or other) activities would you like to see AMPA offer that would be of benefit to your practice or the Air Medical (Critical Care) Transport Community?

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