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The Society is open to all healthcare providers who are actively involved in the delivery of pediatric sedation and all those who wish to advance the society's mission. Individuals who express an interest in pediatric sedation via clinical practice, research and/or education may be a member of the Society for Pediatric Sedation®.

If you have questions about membership, or have difficulty completing this membership application please contact Greg Leasure, Membership Manager, at greg@societyhq.com.

First Name:
Middle Initial (if any):
Last Name:
Degree: MD  PhD   DO  DMD  other (specify):
Mailing Street Address:
City:
State:
Zip/Postal Code:
Country:
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Date of Birth:  /  / 
Email address:
Affiliation:
Select one or more of the following specialties:
Name of SPS member who referred you:
MEMBERSHIP CATEGORIES (Cost based on country and category)
Please visit: http://www.pedsedation.org/membership/membership-tiers/ to find your tier.		 TIER
1		 TIER
2		 TIER
3		 TIER
4
Sustaining Member Any healthcare provider who meets the physician or allied health categories may join by paying the fee established by the Board of Directors. Membership in this category provides the member with special recognition and privilege as determined by the Board of Directors. $200 $200 $200 $200
Physician: Licensed physicians with an interest in pediatric sedation may become a member. $160 $50 $10 $3
Dentist: Any doctor of dental surgery or doctor of dental medicine with an interest in pediatric sedation may become a member. $160 $50 $10 $3
Allied Health/RN: Any licensed healthcare provider who is not a physician may become a member $75 $25 $5 $2
Allied Health/Other: Any licensed healthcare provider who is not a physician may become a member $75 $25 $5 $2
Associate Anyone with an interest in the field of pediatric sedation who does not meet the criteria of any other category may become an associate member. Associate members are not eligible to vote or hold office.
Application will be reviewed by membership committee before granting Associate membership.		 $60 $25 $5 $2
Trainee Any student, or healthcare provider involved in a nursing, child life, or dental training program may become a member. $25 $10 $2 $1
  Trainee Institution:
Location: Graduation/Residency Date: / (MM/YYYY format)
Physician Trainee Complimentary membership to physician trainees (resident and fellows) for the duration of their training. $0 $0 $0 $0
  Physician Trainee Institution:
Location: Graduation Date: / (MM/YYYY format)
Which Committee would you be interested in joining (mandatory for Physician Trainee):
  PAYMENT :

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Card Number:
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Exp. Date: /
Security code:
For VISA or MasterCard it is on the back of your card in the signature box. The 3-digit code is printed on the right-hand side of your 16-digit credit card number.
For American Express the code is the 4-digit number printed on the front of your card either on the right-hand side directly above the credit card number or the left-hand side directly above the credit card number.
Note: This is a secure transaction system. However, if entering your credit card information online makes you uncomfortable, please pay by check. Send all checks to SPS, 2209 Dickens Road, Richmond, VA 23230-2005

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Copyright © 2023 • Society for Pediatric Sedation® • 2209 Dickens Road, Richmond, VA 23230-2005
Phone: 804-565-6354 • Fax: 804-282-0090 • Email: [email protected]
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