Application for Chapter Membership

Kansas Chapter, the American Academy of Pediatrics (KAAP)
9905 Woodstock Street , Lenexa, KS 66220
Phone: 913-780-5649 Fax: 913-780-5651 Email: kansasaap@aol.com Web Site: www.aapkansas.org

Date: _______________________

Name:_______________________________________________Spouse’s Name: ______________________

Address:

Office: _____________________________________________________________Zip ___________________

Phone: ________________________________________Email: __________________________________

Home: _____________________________________________________________Zip ___________________

Phone: ________________________________________

Type of Practice/Training Program

Education:

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Undergraduate College/University Dates attended Degree(s)

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Medical and Other Graduate School

Graduate Training:

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Internship/Residency Hospital Location Dates

Other Special Training (Fellowships or Additional Formal Graduate Training)

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Board Certification: __________________________________________Date: ___________________________

Kansas State Medical License Number: __________________________Exp. Date: _______________________

Society Memberships:
 Kansas Medical Society (Member): __________________________Date: ______________________________

Other Professional Societies and Offices Held: ___________________________________________________

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Committee Interests:

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With the enclosure of my check for $75.00 for annual dues, made payable to the Kansas Chapter of AAP and mail to:

Attn Chris Steege
KAAP
9905 Woodstock Street
Lenexa, KS 66220

I hereby apply for Kansas Chapter membership,

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(Signature)