Chapter Application


To join an SCCM chapter complete the following online application or call SCCM's customer service department at +1 (847) 827-6888. If you are not already an SCCM member and would like to join both the national society and a local chapter, please complete and submit our membership application.

First Name:
Middle Initial:
Last Name:
Gender: Male  Female
Date of Birth:

Professional Information:

Institution / Business:
Title / Position:
Department:
Division:
Street:
City:
State /Province:
Zip / PostalCode:
Country:
Phone:
Fax:
Email Address:

Type of Critical Care Professional:

Other:

Chapter Membership Fees:
A full membership for any chapter is $45.00. Chapter membership is free for anyone currently in training (fellows, residents and students). Please indicate which membership category applies to you and select which chapter you would like to join.

Membership Category:

Full Membership
Training Membership

Chapter:

Baltimore Chapter
California Chapter
Carolina/Virginia Chapter (Virginia, North Carolina, South Carolina)
Michigan Chapter
New England Chapter (Maine, Vermont, New Hampshire, Massachusetts, Connecticut, Rhode Island)
New Jersey Chapter
North Central Chapter (Iowa, Minnesota, North Dakota, South Dakota, Wisconsin)
Ohio Chapter
Oregon Chapter
Pennsylvania Chapter
Southeast Chapter (Arkansas, Louisiana, Kentucky, Tennessee, Mississippi, Alabama, Georgia)
Texas Chapter
Washington, DC Chapter

Primary Board Certification and Last Year Certified:

Other:

Year

Subspecialty Board Certification and Last Year Certified:

Other:

Year

Additional Subspecialty Board Certification and Last Year Certified:

Other:

Year

Allied Health Specialty or Discipline:

Other:

Certifications:

Year

Are You Board Certified in Critical Care Medicine? Yes No
If yes, what was the last year you were certified?

In-Training Information:
(Applicable to fellows, residents and students)

Institution:
Phone:
Program Director:
Date Training Program Began:
Expected Date of Completion:
*Physicians-in-training must submit, by fax or by mail, a letter from their program director verifying position and dates.

Contact Information:
Where would you like to receive your mail? Office Home

Business Address:

Institution / Business:
Department:
Position:
Street:
City:
State or Province:
Zip / Postal:
Country:
Phone:
Fax:
Email:

Home Address:

Street:
City:
State or Province:
Zip / Postal:
Country:
Phone:
Fax:

Payment Options: Credit Card:

DISCOVER VISA MasterCard American Express

I authorize the Society of Critical Care Medicine to charge my fees to the following account:

Name on Card:
Credit Card #:
Expiration Date: