Workgroup Participation Application Form
Name
*
Prefix
First Name
Last Name
Credentials (e.g. MD, PhD, etc.)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Assistant's E-mail
example@example.com
Please List your Primary Specialty
*
Adult Hip
Adult Knee
Adult Spine
Disability/Legal Orthpaedics
Foot and Ankle
Hand
Pediatric
Ortho/Oncology
Pediatric Spine
Rehab/Prosthetics and Orthotics
Shoulder and Elbow
Sports Medicine
Total Joint
Trauma
Other
If you chose "Other" please specify below:
Please list your work setting
*
Academic Practice
Clinical Hospital
Military
Non Military Government or Public
Pre-paid Plan HMO
Private Group or Practice
Other
If you chose "Other" please specify below:
Are you a member of any specialty society?
*
Yes
No
If you chose "Yes" please specify below.
Have you complete/updated your information in the AAOS Orthpaedic Disclosure Program?
*
Yes
No
Have you completed any of the Evidence-Based CME Courses?
Yes
No
Submit
Should be Empty: