Community Member Application Community Member Application 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 organizationI am a patient (over the age of 18) First Name Last Name Degree(s) Email Please enter the year in which you were born.Please select... 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 If applicable, please provide the name of the organization with which you are involved. What is your role in that organization? (OPTIONAL) Please use this space to share any additional information about why you are interested in joining PeDRA as a Community Member: Address - please separate multiple address lines with a comma. City CountryPlease select... 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Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau State/Province ProvincePlease select... Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code What type of address is this? Personal Business Preferred Phone (xxx-xxx-xxxx) Please indicate which areas of pediatric skin disease research interest you most:Acne & Hidradenitis SuppurativaAtopic Dermatitis & PsoriasisBirthmarksConnective Tissue and Autoinflammatory DiseaseDrugs & BugsGenetic Skin DisordersHair DisordersNeonatal SkinSkin of Color & Pigmentary DisordersSkin Tumors and Reactions to Cancer Therapies (STARC)Other Use this space to indicate your other areas of interest: 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.Please select... Female Male Non-binary I do not wish to provide this information. With what race(s) do you self-identify? Please select all that apply.American Indian or Alaskan NativeAsianBlack 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 Hispanic or Latinx Ethnicity: Do you wish to receive emails from PeDRA? Please select all that apply.I’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. 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 we will email you information specific to your participation. How did you hear about PeDRA? Confidentiality AgreementPeDRA 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 Community Members but may be required before participating in certain activities. By checking 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