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ISACCD Home > CHD Community > Join ISACHD > Membership Application Questionnaire

Complimentary Membership Questionnaire

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

ISACHD Complimentary Membership

Please enjoy a complimentary membership for the next two years. At the end of the two complimentary membership you will be invoiced to continue your membership.

Required Fields *

* Applicant:

Name:

* Membership Type:

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

I would like to also join the International ACHD Nursing Network (IACHDNN) within ISACHD. (There is no additional fee.)

* Contact Information

Institution:
Address:
City: State: Zip:
Country:
Phone Number:
Email Address:

Discipline:

Advanced Practice Nurse
Cardiologist
Cardiovascular Surgeon
Certified Nursing Assistant
Pediatric Cardiologist
Physician Assistant
Registered Nurse

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:

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