KCMS Membership Form

Membership Form

Renewing Members and Applicants
Name*

First NameLast Name
Credentials*

MDDO
Email*
example@example.com
Mobile Phone Number*
Please enter a valid phone number.
Membership Renewal Categories

Physician Membership: $120 annually

Medical Students & Residents: Free

Lifetime Retired Physician Membership: $870 one time fee paid by check
Your Payment Method

Credit CardCheck
If you are paying by check, please submit payment to:

KCMS

C/O Micah Flint

210 SW Market Street, Ste. 227

Lee's Summit, MO 64063

Specialty or Primary
Subspecialty
Employer Name (Medical Students or Residents, please provide training center name)
Are you a MSMA Member?

YesNo
Are you a KMS Member?

YesNo

Physician Membership Renewal (if you are not submitting a Physician Membership Renewal, please skip the payment portion and click Submit)

Physician Membership Renewal

$120.00 for each year

Email

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty: