2018 GPA Membership Form

2021 GPA Membership Form
Renew your current membership or become a new member for only $50. Your membership will be valid through December 31, 2021.

Please complete the information below and submit. You can use the paypal payment feature or you can print a copy of your submission and mail it together with a check to Georgia Perinatal Association, PO Box 13784, Savannah, GA 31416.
Name *

First Name Last Name
Credentials *
Specialty (i.e. OBGYN, perinatal, neonatal, pediatrician, etc.) *
Please enter None if you don't have any.
Number of years in your profession: *
Job Setting: *

Academia Ambulatory (physician office, outpatient, clinics, etc) Home Health Care Hospital Inpatient Not Working Public Health
Referred By:

First Name Last Name
Home Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Personal Email
example@example.com
Place of Employment
Employment Title
Work Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Work Phone

Area Code Phone Number
Work Email
example@example.com
Preferred method to email you

Work Email Personal Email
Preferred method to call you

Home Phone Work Phone Cell Phone
Are you interested in serving on any of these committees?

Nominating By-Laws Education Newsletter Program Public Policy
How did you hear about GPA?

Email Facebook Twitter Instagram Website Friend
If you were referred by a friend, please enter the name below?
Check Issued by (company name or individual name):
Member Name (please ensure this is noted on the check):
Anticipated check receipt date:
UPLOAD ATTACHMENTS

Please submit the necessary documents below
For a student membership, please upload a letter from registration office here

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For a military membership, please upload your military ID here

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For an organization membership when signing up 5 or more members at the same time, please list all full names below
DEMOGRAPHIC INFORMATION

As a 501c3 member of the Community Foundation of Greater Atlanta, we are requested to ask you for the following information:
What is your gender?

Male Female Do not wish to disclose
What is your race/ethnicity?

African American Native American Hispanic White Do not wish to disclose
What is your age?
Enter 0 if you do not want to disclose
What County do you reside in?
Enter N/A if you do not want to disclose
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2021 Professional Membership (LPN, RN, NP, MD, Social Worker, etc) $ 50.00

2021 Student Membership (must upload current course schedule) $ 25.00

2021 Military Membership (Active, Retired, Spouse - must upload military ID below) $ 40.00

2021 Organization Membership (price per person for 5 or more members joining at the same time) $ 40.00

2021 Advocate Membership (for those that support GPA financially and the mission publicly) $ 100.00

Total $ 0.00

Payment Methods

Debit or Credit Card

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Please click one of the PayPal options to complete payment and submit the form.

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2021 GPA Membership Form

UPLOAD ATTACHMENTS

DEMOGRAPHIC INFORMATION