International Society for Adult Congenital Cardiac Disease (ISACCD)

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ISACCD Home > CHD Community > Join ISACCD > Membership Application Questionaire

Membership Questionnaire

This questionnaire must be completed in order to become a member of the ISACCD. The data is only for statistical purposes and does NOT influence the applicant's eligibility for membership. All fields are required, except for "Sponsor".

Applicant:

Name:

Membership Type:

Physician/Surgeon
Professional (Nurses, Physician Assistants and other healthcare providers
In-Training

Discipline:

Cardiologist
Registered Nurse
Pediatric Cardiologist
Cardiovascular Surgeon
Other:

Education:

Institution:
City: State: Zip:
Date Graduated: Degree:

Medical and/or other professional society memberships:

(If none, enter "none".)

Hospital affiliation:

Type of institution:

Private
Veterans Administration
University
City or County
Other:

Size of institution:

Patient Population:

Experience with adults with congenital heart disease

Sponsor (if applicable)

Name:

You will be redirected to our secure membership sign-up page. Thank you.

International Society for Adult Congenital Cardiac Disease
1500 Sunday Drive, Suite 102
Raleigh, NC 27607
United States of America
Phone: 919-861-5578
Fax: 919-787-4916