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
- 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
This field is for validation purposes and should be left unchanged.