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Pediatric Endocrine Society

Formerly Named in Honor of Lawson Wilkins

Membership Application


PEDIATRIC ENDOCRINE SOCIETY
Application for Advanced Practice Provider Membership

 

Please verify the following

I am currently certified by a nationally recognized certifying body pertinent to my specialty
I have a minimum of one year of clinical or research-based practice within the subspecialty of pediatric endocrinology
 
First Name:
Last Name:
Degrees: (30 characters max)
Title:
Organization/Institution:
Department/Division:
Address:
City:
State or Province:
(N/A if not applicable)
Zip/Postal Code:
Country:
Business Phone:
Fax:
Email:

Date of Certification (year):
Enter certification number:


Date of completion of an accredited graduate level (master's or doctoral degree) NP/APN/PA program:
 


Curriculum Vitae must include references to:
  • All post graduate training
  • All specialty board certifications, including certificate numbers and dates
  • Employment history
  • Membership in other societies
  • Bibliography (note which papers are peer reviewed)
Upload your CV:


Direct Supervisory Physician:


Upload a Letter of Recommendation:
Note: If your immediate supervisor is not a member of PES, please upload a letter of support from a Regular Member of PES, with specific attention to your contributions to the field.
 
 
 

Work Setting (Choose all that apply)

Private Solo Practice
Private Group Practice
Hospital
HMO
Government
Industry
University/Academic
Other:
 
 

Allocation of Time

On average, how many hours per week do you work in the field of pediatric endocrinology?

Out of your hours worked per week, please include the percentage of time worked in each area. Please enter without a percent sign.
Basic Research:%
Clinical Research:%
Other Research (example: healthcare delivery, clinical quality improvement, etc.):%
Patient Care (includes administrative time):%
Teaching fellows, residents, and/or students:%
Administration that directly relates to pediatric endocrinology (excluding patient care):%
Other: %
 
Do you expect the balance of your activities (patient care, research, administration, etc.) to change in the next 5 years?
Yes
No
 
Approximately how many patients do you see per week?
 
 

Interests (Select all that apply)

Clinical
Adrenal Cortex
Adrenal Medulla

Research Activities
Basic Science Research - Diabetes
Basic Science Research - Endocrinology

Clinical
Bone Disorders
Diabetes
Genetics
Growth
Hypoglycemia/Carbohydrate Metabolism Disorders other than diabetes
Lipid Metabolism
Neuroendocrinology
Obesity
Ovary
Parathyroid/Calcium Homeostasis
Pituitary, Anterior
Pituitary, Posterior
Puberty
Sex Development
Testis
Thyroid

Other Interests
Other

Clinical
Endocrine Oncology
Transgender Care
Salt-Water Metabolism

Research Activities
Clinical Research - Endocrinology
Clinical Research - Diabetes
Translational Research - Endocrinology
Translational Research - Diabetes

Other Interests
Health Service Delivery
Medical Education
Medical Informatics

Research Activities
Quality Improvement
Other

 

Other

Year Born

Besides English, do you speak any other languages fluently?
Yes
No

 
Are you planning to retire in the next 5 years?

I am already retired
Yes
No
No, but I plan on cutting back my work hours

 
We welcome any other comments or suggestions that you may have. Leave us a note here!
 
 


Please mark your answer to each of the following statements:


Name, Address, Phone, Email (Member Only Directory online)
You may publish my name, address, phone number, and email in the membership directory for members only.
Yes
No


Name, Address, and Phone for Public Access (Find a Doc)
You may publish my name and address in the "Find a Doc" section of the web for public access.
(Members' email addresses will not be published on the public access section of the Website.)
Yes
No

Dues payment method

Credit Card
Check / Mail in Payment

Note: If you are from a low or middle-income country, you may be eligible for reduced dues. Click here for more information.