PPAG -Pediatric Pharmacy Advocacy Group The Pediatric Pharmacy Advocacy Group
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PPAG
7953 Stage Hills Blvd. Suite 101
Memphis, TN 38133
T: 901.380.3617
F: 901.266.4751

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Pharmacists improving medication therapy in children


PPAG Membership Application

To join, fill out the fields below, or download application to pay by check:  Membership Application
 
Section 1: Personal Information
First Name*
  
Initial
  
Last Name*
  
Company
  
Position Title
  
Sponsor or Recruiter
Name of member who recruited you to join PPAG.

 
 
Section 2: Primary Contact Information
E-mail*
  
Providing your e-mail address allows you to receive timely information. we do not sell or distribute e-mail addresses.

 
Mailing Address*
  
Address 2*
  
City*
  
State*
  
Zip*
  
Country*
  
Address Type*
  
Work Phone*
  
Home Phone
  
Mobile Phone
  
Pager
  
Fax
  
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Section 3: Additional Contact Information (optional)
E-mail 2
  
Address
  
Address 2
  
City
  
State
  
Zip Code
  
Country
  
Address Type
  
 
Section 4: Professional Practice Information
Professional Degree(s)   
 
Certifications*
  
Please list all certifications, seperated with a comma

 
How long in practice?*   
 
Licensed in State*
  
Areas of Expertise*   
  Ambulatory Care
Cardiology
Critical Care
General Peds
Hematology/Oncology
Infectious Disease
Informatics
Intensive Care
Medication Safety
Neonatal Pharmacy
Nutrition/GI
Pediatric Formulation
Pharmacy Administration
Pulmonary
Teaching
Technology
Transplantation
Urology/Nephrology
Women's Health
 
 
Section 5: Subscribe to Groups
Local Network
 
Please indicate if you are a member of one of our recognized local networks.

 
Join a Committee
Advocacy Committee
Education Committee
Finance and Audit Committee
Fundraising Committee
Member Services Committee
Research Committee
 
 
Section 6: Payment
Membership Type*
 $190.00 - Associate Member: Eligible only if he/she is a non-pharmacist committed to the goals of this organization or a pharmacist not actively involved in institutional pharmacy practice.
$190.00 - Individual Member: Eligible only if he/she is a pharmacist committed to the goals of this organization and is actively involved in or has substantial experience in pediatric pharmacy practice.
$60.00 - Pharmacy Technician: Does not include receipt of the Journal of Pediatric Pharmacy Practice.
$60.00 - Resident/Fellow Member: Eligible only if he/she is a pharmacist in a residency or fellowship program. (Proof required)
$40.00 - Student: Eligible only if he/she is a student in an accredited school of pharmacy. (Proof required)
 
Payment Method*
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