MEMBERSHIP APPLICATION

Membership in the AADCAP 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 $200.00 for the calendar year and $100 (after July 1). Complete and mail this form (all fields are required):

Name*
Title*
Institution*
Mailing Address*
City*
State*
Zip code*
Phone Number*
Fax Number*
Email Address*
Please check all that apply to your position in your division*	Division Director Division Director and Residency Training Director Director of Psychiatry
Payment type*	Credit Card Check (payable to SPCAP)
Credit Card Type*	Visa MasterCard
CVV*
$
Credit Card #
Exp. Date:*
Name on Card*
Signature*
Billing Address information*

Please email this form with payment to: Earl Magee, AADCAP Executive Director,

and a letter of verification with this application at info@aadcap.org.

Thank you!