ASPO-HNS Membership Application Form

  • ASPO-HNS Membership Application

  • Which membership type are you applying for?

  • Fellow Member Application

    Fellow Membership is intended for physicians currently enrolled in a pediatric otolaryngology fellowship program or those who have completed fellowship training within the past three years. This membership category provides opportunities for education, networking, and professional development as fellows transition into practice. Fellow Members may participate in ASPO-HNS activities but are not eligible to vote or hold elected office.

  • General Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Are you currently a Resident member of ASPO-HNS?*

  • Educational Background

  • Professional Activities/Academic Appointments/Hospital Staff Appointments

     Please list any and all professional activities, including academic and hospital staff appointments, from the completion of your training until present. Use the allotted text box to add as many fields as needed. For each activity ensure you include: 

    1. Your Title/Rank

    2. The Institution/Location

    3. Dates of Participation

     

     

  • Certification and Professional Society Affiliations

  • Are you certified by:*
  • Are you a member of AAO-HNS?*
  • Are you a member of an international equivalent AAO-HNS?*

  • Please list any other Professional Societies or Organizations to which you belong: 

    Use the allotted text box to type in as many fields as needed. For each activity ensure you include: 

    1. Society Name

    2. Position/Office Held

    3. Dates of Participation

  • Please list the ASPO-HNS Meetings you have attended in the past three (3) years. 

    In order to be eligible for membership, applicants must have attended one ASPO meeting in the three years prior to application. Include: 

    1. Location

    2. Year

  • References

    A total of 2 reference letters are required for the Fellow application. 1 must be from your Fellowship Director, and 1 must be from an active ASPO-HNS member.  

  • Reference 1: Director of your Pediatric Otolaryngology Fellowship Training Program 

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  • Reference 2:

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  • Final Attachments

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  • Resident Member Application

    Resident Membership is intended for otolaryngology residents with an interest in pediatric otolaryngology and future fellowship training. This category allows residents to become engaged with ASPO-HNS through educational programs, mentorship opportunities, and committee service. Resident Members may serve as non-voting members on committees but are not eligible to vote or hold elected office.

  • General Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Are you currently a Resident member of ASPO-HNS?*

  • Educational Background

  • Professional Activities/Academic Appointments/Hospital Staff Appointments

     Please list any and all professional activities, including academic and hospital staff appointments, from the completion of your training until present. Use the allotted text box to add as many fields as needed. For each activity ensure you include: 

    1. Your Title/Rank

    2. The Institution/Location

    3. Dates of Participation

     

     

  • Certification and Professional Society Affiliations

  • Are you certified by:*
  • Are you a member of AAO-HNS?*
  • Are you a member of an international equivalent AAO-HNS?*

  • Please list any other Professional Societies or Organizations to which you belong: 

    Use the allotted text box to type in as many fields as needed. For each activity ensure you include: 

    1. Society Name

    2. Position/Office Held

    3. Dates of Participation

  • Please list the ASPO-HNS Meeting you have attended, or submitted an abstract for consideration, during medical school or residency. 

    In order to be eligible for membership, applicants must have attended or submitted an abstract to one ASPO meeting in the three years prior to application. Include: 

    1. Location

    2. Year

  • References

    A total of 2 reference letters are required for the Resident application. 1 must be from your Residency Program Director, and 1 must be from an active ASPO-HNS member.

  • Reference 1: Director of your Residency Program 

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  • Reference 2:

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  • Final Attachments

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  • Full Member Application

    Full Membership is intended for pediatric otolaryngologists whose clinical practice is primarily focused on the care of children. Full Members are established practitioners who have completed fellowship training in pediatric otolaryngology and have demonstrated professional contributions to the specialty. Full Members are eligible to vote, serve on committees, and hold elected office within ASPO-HNS.

  • General Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Are you currently a Fellow member of ASPO-HNS?*

  • Educational Background

  • Professional Activities/Academic Appointments/Hospital Staff Appointments

     Please list any and all professional activities, including academic and hospital staff appointments, from the completion of your training until present. Use the allotted text box to add as many fields as needed. For each activity ensure you include: 

    1. Your Title/Rank

    2. The Institution/Location

    3. Dates of Participation

     

     

  • Certification and Professional Society Affiliations

  • Are you certified by:*
  • Are you a member of AAO-HNS?*
  • Are you a member of an international equivalent AAO-HNS?*

  • Please list any other Professional Societies or Organizations to which you belong: 

    Use the allotted text box to type in as many fields as needed. For each activity ensure you include: 

    1. Society Name

    2. Position/Office Held

    3. Dates of Participation

  • Please list the ASPO-HNS Meetings you have attended in the past three (3) years. 

    In order to be eligible for membership, applicants must have attended one ASPO meeting in the three years prior to application. Include: 

    1. Location

    2. Year

  • References

    A total of 2 reference letters, both from active ASPO-HNS FULL members, are required for the Full Member application. 

  • Reference 1:  

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  • Reference 2:

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  • Final Attachments

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  • International Member Application

    International Membership is intended for pediatric otolaryngologists practicing outside the United States and Canada who have demonstrated expertise and ongoing involvement in the field of pediatric otolaryngology. International Members are eligible to participate in ASPO-HNS activities and serve on committees but are not eligible to vote or hold elected office.

  • General Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     - -

  • Educational Background

  • Professional Activities/Academic Appointments/Hospital Staff Appointments

     Please list any and all professional activities, including academic and hospital staff appointments, from the completion of your training until present. Use the allotted text box to add as many fields as needed. For each activity ensure you include: 

    1. Your Title/Rank

    2. The Institution/Location

    3. Dates of Participation

     

     

  • Certification and Professional Society Affiliations

  • Are you certified by:*
  • Are you a member of AAO-HNS?*
  • Are you a member of an international equivalent AAO-HNS?*

  • Please list any other Professional Societies or Organizations to which you belong: 

    Use the allotted text box to type in as many fields as needed. For each activity ensure you include: 

    1. Society Name

    2. Position/Office Held

    3. Dates of Participation

  • Please list the ASPO-HNS Meetings you have attended in the past three (3) years. 

    In order to be eligible for membership, applicants must have attended one ASPO meeting in the three years prior to application. Include: 

    1. Location

    2. Year

  • References

    A total of 2 reference letters, from two (2) colleagues indicating the applicant's focus on pediatric otolaryngology. 

  • Reference 1:  

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  • Reference 2:

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  • Final Attachments

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  • APP Member Application

    APP Membership is intended for Nurse Practitioners, Physician Assistants, and equivalent advanced practice providers who are actively involved in the care of pediatric otolaryngology patients. This category recognizes the important role APPs play in multidisciplinary pediatric otolaryngology care. APP Members are eligible to vote and serve on committees but are not eligible to hold elected office.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     - -

  • Educational Background

  • Professional Activities/Academic Appointments/Hospital Staff Appointments

     Please list any and all professional activities, including academic and hospital staff appointments, from the completion of your training until present. Use the allotted text box to add as many fields as needed. For each activity ensure you include: 

    1. Your Title/Rank

    2. The Institution/Location

    3. Dates of Participation

     

     

  • Certification and Professional Society Affiliations

  • Do you have a certification as a CRNP (Certified Registered Nurse Prescriber or Physician Assistant) in family practice or pediatric and an active unrestricted license to practice pediatric medicine in the United States or Canada*
  • Do you have privileges at a Children's hospital or pediatric center within a general hospital to practice pediatrics or family medicine?*
  • Are you a member of AAO-HNS?*
  • Are you a member of an international equivalent AAO-HNS?*

  • Please list any other Professional Societies or Organizations to which you belong: 

    Use the allotted text box to type in as many fields as needed. For each activity ensure you include: 

    1. Society Name

    2. Position/Office Held

    3. Dates of Participation

  • Please list the ASPO-HNS Meetings you have attended in the past three (3) years. 

    In order to be eligible for membership, applicants must have attended one ASPO meeting in the three years prior to application. Include: 

    1. Location

    2. Year

  • References

    A total of 1 reference letter, from an active ASPO-HNS FULL member, is required for the Intnernational application.  

  • Reference 1:  

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  • Reference 2: Optional

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  • Final Attachments

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  • Payment*

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    Full Member Application Fee Product Image
    Full Member Application Fee
    $100.00$100.00
      
    APP Member Application Fee Product Image
    APP Member Application Fee
    $100.00$100.00
      
    Fellow Member Application Fee Product Image
    Fellow Member Application Fee
    Free$ Free
      
    APP Member Application Fee Product Image
    APP Member Application Fee
    Free$ Free
      
    Resident Member Application Fee Product Image
    Resident Member Application Fee


    Free$ Free
      
    Total
    $0.00$0.00
    Credit Card
    Billing Address
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