RPS Membership Application

Membership Application

Membership form (all fields with an * are required). Contact rps@ramdocs.org with questions.
Member Information
Name:*

First NameLast Name
Degree:*
MD, DO, PhD, NP, etc.
Primary Email Address:*
Please enter the email address you'd prefer we use to contact you.
Cell Phone Number
I am retired.*

YesNo
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Information
Employer Name *
Employer Phone:
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Membership Options
How would you like to pay?*

Pay online (Your payment will show on your credit card statement as Richmond Academy of Medicine Trust, the fiscal agent of the Richmond Pediatric Society. All donations are restricted to the Richmond Pediatric Society.)Pay by check
Make checks payable to RAM Trust and mail to:

RAM Trust

Attn: Richmond Pediatric Society
2821 Emerywood Parkway
Suite 200
Richmond, VA 23294
Online Membership Options*
prevnext( X )
Active MembershipMDs, DOs, PAs, NPs, and PhDs in the Greater Richmond Metro area who work with children.
$105.00



Associate MembershipRNs, LPNs, LCSWs, and PTs in the Greater Richmond Metro area who work with children.
$80.00



LearnersStudents, medical students, residents, interns, and fellows in the Greater Richmond Metro area who are actively learning how to care for children.
$ Free



Total

$0.00
Membership Options (paying by check)

Active - $100Associate - $75Learners - $0
If paying for multiple memberships, please list all names here:
Should be Empty:

Membership Application

Member Information

Employer Information

Membership Options