CCMSA Member Registration Page

CCMSA

Membership Application

I am a...
My Spouse is a ...

Membership limited to physician or physician spouses only

Member Information

First Name

Last Name

Occupation

Specialty

Member Contact Info

Phone

Spouse Information

You listed that your spouse is a physician. Please enter their name and specialty below

First Name

Last Name

MD/DO

Specialty

Practice Name

Practice Phone

Membership Type

	Regular Member	$125
	Associate Member: Resident/Widow/Retired/Military	$30

I have an interest in the following special interest groups

Book Club

Toddler Play Group

Cooking Club

Dining Group

Fitness/Nutrition

Are you interested in leading/starting a special interest group

Yes

I would like information on the following committees: (choose all that apply)

Legislative

Fashion Show

Community Health/Outreach

Healthcare Scholarship Project

Purchase Summary

Please review your registration booking fee below.

Regular Membership
Credit Card and Service Fee		$7.12

Due Now:

Automatic Yearly Renewals

Payment Information

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Unless you otherwise direct in writing, the information provided herein, will be placed in the Membership Directory, provided to Members ONLY. I agree that CCMSA may use photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.