MMDA Membership Application

MMDA Membership Form
MMDA Membership Benefits:

• Access to members-only benefits.

• Advocacy: Leadership, education, and advocacy on federal and state-level issues affecting our patients, residents, colleagues and community

Annual Scientific Meeting:
• CEUs for physicians, APNs, and medical directors
• Discounted registration fee for members

You can register to become a member or renew your MMDA membership online. Our membership year begins every January 1 and ends on December 31 of the same calendar year. Payment of dues applies to the calendar year when the payment is received, except during the 3 month period prior to January 1. Dues paid during the 3 months prior to the following date of January 1 will be applied to the coming calendar year. For example, paying dues on October 1, will provide membership for 1/1/xx – 12/31/xx. However, payment of dues on September 30, or before will provide membership for the prior year

Please complete the fields in the membership application below and then click on the submit button. After you successfully submit your application, please return to this page to make your online payment for your membership using the secure online Stripe payment system. If you have any questions about membership, please contact MMDA at mmdawebsite@gmail.com.
Application for MMDA Membership
Name

First NameLast Name
Name of facility or organization.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I currently serve in a PALTC setting as a ..

Other
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General Members
Physicians, Advanced Practice Nurses, and Physician Assistants in practice

$150.00 Quantity



Affiliate Members
Nurses, DONs, ADONs, DDSs, CNSs, DPMs, and other interdisciplinary team members

$75.00 Quantity



Emeritus Members
Retired

$40.00 Quantity



Student Members
Students of all disciplines, Residents, and Fellows

Free Quantity



Total

$0.00
You may also email the paper form to mmdawebsite@gmail.com, fax to (561) 689-6324, or mail the check separately. If you have questions regarding membership, please visit https://midatlantic.paltmed.org/, email mmdawebsite@gmail.com, or call Ian Cordes, Administrator, at (561) 689-6321.

MMDA – The Mid-Atlantic Society for Post-Acute and Long-Term Care Medicine, Inc. 3123 Breakwater Court, West Palm Beach, FL 33411
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MMDA Membership Form

Application for MMDA Membership

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