Community Member Application

Thank you for your interest in becoming a PeDRA Member! Please complete the form below. If you have any questions regarding the application process, please email us at info@pedraresearch.org.

Please select your membership category:

Active - $150 (Investigators and/or clinicians)Affiliate - $100 (PhD scientists, allied health professionals, research coordinators) Trainee - Free (Students, Residents, or Fellows)Community - Free (Parent, Advocate, or Patient over 18)If you're already a PeDRA Member, you don't need to reapply. Please renew your membership on the PeDRA Membership page on our website.

First Name

Last Name

Degree(s)

Are you a:

Medical StudentGraduate StudentDermatology ResidentClinical FellowPre-doctoral Research FellowPost-doctoral Clinical FellowPost-doctoral Research FellowOther - Write in below

Other position or trainee status and/or additional information:

Please tell us more about yourself. Select all that apply:

I am the parent or guardian of a pediatric patient.I am a representative from a patient advocacy organization.I am a patient (over the age of 18).

Please enter the year in which you were born.

The email you provide will be linked to your PeDRA Membership profile and will be used by you to access the PeDRA website and PeDRA member app.

Phone

Mobile

Home

Office

Primary Institution/Affiliation

What is your role in that organization?

Address Line (please separate multiple lines with a comma)

Home

Office

City

State

Country

Postal Code

Department/Division

Position

In what year did you complete your training?

ex: 2002

Are you interested in joining one of PeDRA's research Focused Study Groups (FSG)? Check all FSGs that you'd like to join and be notified of upcoming meetings.

Acne/HSAD/PsoriasisBirthmarksConnective Tissue DiseaseDrugs & BugsEducationGeneticsHair DisordersNeonatal SkinSkin of Color & Pigmentary DisordersSkin Tumors and Reactions to Cancer Therapies (STARC)Down Syndrome Subgroup

Please indicate which areas of pediatric skin disease research interest you most:

Acne/HSAD/PsoriasisBirthmarksConnective Tissue DiseaseDrugs & BugsGeneticsHair DisordersNeonatal SkinSkin of Color & Pigmentary DisordersSkin Tumors and Reactions to Cancer Therapies (STARC)Down Syndrome Subgroup

Training Program

Program Director

Program Director Email

Start Date of Training

ex: 2021

End Date of Training

ex: 2024

What year do you anticipate completing your highest level of training including your post-doctoral clinical fellowship?

ex: 2024

Please provide your current position.

Please provide the name and email address of a mentor, supervisor, or other clinician and/or researcher who can serve as a professional academic reference. Please note, that the approval of your application will be delayed if you don't provide this information.

First and last name of reference:

Email address of reference:

Position and institution of reference:

If known, what institution will you be attending for your residency?

If known, what institution will you be attending for your fellowship?

If applicable, what institution will you be moving to as an attending?

Please provide a brief bio about your work in pediatric dermatology.

250 characters maximum

Please provide a brief statement of interest.

Please note, that the approval of your application will be delayed if you don't provide a statement of interest.

Please use this space to share any additional information about why you are interested in joining PeDRA as a Community Member:

Do you wish to receive emails from PeDRA? Please select all that apply.

I’d like to receive the PeDRA Research Bullet monthly e-newsletterI’d like to receive the monthly PeDRA Education Report that highlights PeDRA’s latest educational offerings.I'd like to receive emails to participate in PeDRA member's surveys (not including the PeDRA annual member survey, which you will receive by default).I'd like to receive emails about PeDRA grants, events, and other general programs and opportunities.No, I don't wish to receive any emails from PeDRA outside of information about my PeDRA membership.*

*If you register for a PeDRA event or indicated above that you're interested in joining one of PeDRA's Focused Study Groups, we will email you information specific to your participation.

How did you hear about PeDRA?

Do you have a discount code?

YesNo

Demographic Information

PeDRA is committed to supporting equity, diversity, and inclusion (EDI) across all facets of its organization, programs, committees, leadership, and research studies. One of the ways PeDRA intends to do this is by increasing UIM representation in PeDRA membership, and we need your help ensuring we have complete data to achieve this goal. De-identified aggregate data may be used for PeDRA’s EDI initiatives, but no identifiable information that you provide will be shared without your consent.

Please specify your gender.

With what race(s) do you self-identify? Please select all that apply.

American Indian or Alaskan Native AsianBlack or African AmericanMiddle Eastern or North AfricanNative Hawaiian or Other Pacific IslanderWhiteOther - Write In belowI do not wish to provide this information.

Other Race(s) and/or Additional Information:

What is your ethnicity?

Hispanic or LatinxNot Hispanic or LatinxI do not wish to provide this information.

Please provide additional information about your Hispanic or Latinx ethnicity.

CubanMexicanPuerto RicanOther Hispanic or Latinx Ethnicity - Write In Below

Other Ethnicity:

Confidentiality Agreement

PeDRA is committed to protecting confidential and sensitive information related to unpublished research ideas, methods data, results, and proposals. Click here to view the PeDRA Confidentiality Agreement . Agreeing to the confidentiality agreement is OPTIONAL for PeDRA Members but may be required before participating in certain activities.

By selecting this box I certify that I have read and will abide by PeDRA's Confidentiality Agreement.

Confirmation of Eligibility

Community Membership is available to parents, advocates, and/or patients over the age of 18 who are ineligible for PeDRA membership in any other category and who are not employed by a company that is a current partner of PeDRA or involved in the marketing or development of products relevant to the field of pediatric dermatology. Please use the space below to confirm your eligibility as a Community Member.

By checking this box I certify that I am not eligible to join PeDRA as an Active, Trainee, or Affiliate member.

By checking this box I certify that I am not employed by a company that is a current partner of PeDRA or involved in the marketing or development of products relevant to the field of pediatric dermatology.

Contact Information

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