NMPRA Membership Form
(Programs/Groups)

Hand with PenThank you very much for your interest in joining NMPRA.

Currently membership is free through June, 30, 2002.

Membership entitles you to our quarterly newsletter, participation in nmpra-l, and the ability to apply for our two $1,000 scholarships.

To have the MedPeds Residents of your program become members, fill out the form below.


1. Program Information

Name of Program                              
Address Line 1 of Program                    
Address Line 2 of Program                    
City                                         
State                                         
Zip Code                                     


2. Program Director's Information

Program Director's First name                
Program Director's Last name                 
Program Director's Phone number              
Program Director's Email address              


3. Program Coordinator's Information

Program Coordinator's First name             
Program Coordinator's Last name              
Program Coordinator's Phone number           
Program Coordinator's Email address          


4. Program Chief Resident Information

Does your Program have a MedPeds Chief Resident?                 
  (if No, skip to Section 5)
Program Representative's First name          
Program Representative's Last name           
Program Representative's Phone number        
Program Representative's Email address         


5. MedPeds Residents
   First      Last       Address      Address       City       State Zip   Email         PGY
   Name       Name       Line 1       Line 2
   
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