Membership Form

Name*
First Last
Credential
Flight Program/Facility*
Preferred Mailing Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Phone
International Phone
Fax
Email*
Select Membership*
- Founding Member - (Physician, Voting) $375
- Active Member - (Physician, Voting) $375
- INTERNATIONAL Non-North American Active Member (physician, voting)
- Affiliate - (Transport Service, or Non-physician Medical Professional) $150
- Medical Student/Resident/Fellow - (Documentation Required) $100
Academic Membership - available to Residency Programs. Please contact the AMPA office at 801-263-2672 for details.
Please complete the following to help AMPA better serve you. Is your transport program (check all that apply)
- Rotor Wing
- Fixed Wing
- Ground
- Hospital-Affiliated
- Free Standing
- For Profit
- Not-For-Profit
What is your medical specialty?
Your Position with the transport program:
- Medical Director
- Flight Physician
- Other
Check your Credentials that apply
- MD
- DO
If you are a Medical Director, how long have you had this position?
How much time weekly do you spend on medical direction?
Is your transport service CAMTS certified?
- Yes
- No
How did you hear about AMPA? (i.e. colleagues, journal ad, etc.)
What is your motivation to become an AMPA member or to renew your membership?
Comments
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