2018 GPA Membership Form

2025 - 2026 GPA Membership Form
Renew your current membership or become a new member for only $50. Your membership will be valid from January 1, 2025 through June 30, 2026. We will be shifting our membership year from January through December to July through June so this first membership will be valid for 18 months.

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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2025 Professional Membership (LPN, RN, NP, MD, Social Worker, etc)$50.00

2025 Student Membership (must upload current course schedule)$25.00

2025 Military Membership (Active, Retired, Spouse - must upload military ID below)$40.00

2025 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

Choose from one of the PayPal options to make your payment.

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2025 - 2026 GPA Membership Form

UPLOAD ATTACHMENTS

DEMOGRAPHIC INFORMATION