Membership Application Form

Please select your membership category*

Need help choosing your category? Click here to see PeDRA’s membership descriptions.

Name

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First name

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Last name

Email*

Phone Type

Phone Number

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are you a representative from a patient advocacy organization?*

Yes
No

Primary Institution / Affiliation*

Department / Division*

Primary Institution / Affiliation*

Position*

Year Completed Training*

Are you a…*

If Other, please specify

Are you a…*

If Other, please specify

Anticipated medical school completion date*

Brief statement of interest*

Reference requirement: Your reference should speak to your commitment to pediatric dermatology and your research background.

Reference name*

Reference email*

Degrees (select all that apply)*

If Other, please specify

Research Areas of Interest (select all that apply)

Explore PeDRA Focused Study Groups

Focused Study Groups*

As part of your membership you will receive bimonthly newsletters. In addition, would you like to receive emails inviting you to participate in PeDRA member surveys (apart from the annual member survey you will receive by default)?*

Yes
No

PeDRA is committed to supporting equity, diversity, and inclusion (EDI) across all facets of its organization, programs, and research. Please answer the following optional questions to help ensure we have complete data to achieve this goal. Your answers will be de-identified and aggregated. De-identified aggregate data are for administrative purposes only and may be used to support PeDRA’s EDI initiatives. 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 Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefer not to say
Other

If Other, please specify

What is your ethnicity?

Hispanic or Latinx

Not Hispanic or Latinx

I do not wish to provide this information.

How did you hear about PeDRA?

If Other, please specify

Confidentiality Agreement

Read the Confidentiality Agreement

I have read and will abide by PeDRA's Confidentiality Agreement.*
I agree

First Day Joined
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PeDRA New Member Application

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