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

Address

Spouse Information

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

First Name

Last Name

Specialty

Practice Name

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

Please enter your payment information below...

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.