2018 GPA Membership Form

2024 GPA Membership Form
Renew your current membership or become a new member for only $50. Your membership will be valid through December 31, 2024.

Please complete the information below and submit it. 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 30521, Savannah, GA 31410.
Name*

First NameLast 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:*

AcademiaAmbulatory (physician office, outpatient, clinics, etc)Home Health CareHospital InpatientNot WorkingPublic HealthOther
Referred By:

First NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone

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

Work EmailPersonal Email
Preferred method to call you

Home PhoneWork PhoneCell Phone
Are you interested in serving on any of these committees?

NominatingBy-LawsEducationNewsletterProgramPublic Policy
How did you hear about GPA?

EmailFacebookTwitterInstagramWebsiteFriend
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?

MaleFemaleDo not wish to disclose
What is your race/ethnicity?

African AmericanNative AmericanHispanicWhiteDo 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
My Products
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2024 Professional Membership (LPN, RN, NP, MD, Social Worker, etc)$50.00

2024 Student Membership (must upload current course schedule)$25.00

2024 Military Membership (Active, Retired, Spouse - must upload military ID below)$40.00

2024 Organization Membership (price per person for 5 or more members joining at the same time)$40.00

Total $0.00

Payment Methods

Debit or Credit Card

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

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2024 GPA Membership Form

UPLOAD ATTACHMENTS

DEMOGRAPHIC INFORMATION