Become an APFED Member

Name*

Prefix First Last Suffix

Email*

Phone*

Address*

If you sign up for a paid membership, this must be your billing address.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationships*

What is your relationship to eosinophil-associated diseases? Please select all that apply. After you select a relationship, applicable membership levels will appear as an option further down the form.

Patient
Parent of patient
Family of patient (e.g., brother, aunt, grandparent, cousin)
Spouse of patient
Friend of patient
Clinician
Researcher
None

Patient's year of birth

Optional

What type of clinician are you?

What age patients do you treat?

Pediatric patients
Adult patients
Both pediatric and adult patients

Disease subsets*

Please indicate what eosinophil-associated disease(s) you are impacted by.

Other subset

Please specify what other subsets you are interested in.

Personal Membership Level

Please select a membership level.

Honorary Member ($0)
Steward Member ($30)
Advocate Member ($100)
Patron Member ($250)
Scholar Member ($500)
Champion Member ($2,001)

Professional Membership Level

Please select a membership level.

Honorary Professional Membership ($0)
Individual Professional Membership ($100)
Professional Group Membership ($250)

Can we count on you for an additional donation?

Please enter your desired additional donation amount below.

Total

The total will update after you select a membership level, and also reflect if you make an additional donation.

$0.00

Would you like to have information about you and your practice listed in APFED's Specialist Finder?

Patients and their caregivers use APFED's Specialist Finder to search for health care providers.

Yes, I consent to having my information in APFED's Specialist Finder
No, please do not include my information in APFED's Specialist Finder

Practice Name

Practice Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Practice Phone

Practice Website

Are you a member/affiliate of the following organizations?

If so, check the box(es) below to have badges indicating your membership displayed on your Specialist Finder listing.

International Eosinophil Society
CEGIR

How did you first learn about APFED?*

APFED's Contact List

To be added to APFED's contact list and receive emails, please check the box below.

By checking this box, I am requesting to be subscribed to APFED’s email list, including APFED’s monthly e-newsletter containing information about current events and news of interest.

Legal*

I hereby acknowledge that I have read and agree to APFED's Terms of Use and Privacy Policy.

Credit Card

Please note: The address and phone number you entered above must match the billing information for the credit card used to pay for your membership or the transaction will decline.

Card Details

Cardholder Name

Name

This field is for validation purposes and should be left unchanged.