Thank you for your interest in becoming a PeDRA Member! Please note, we have a new Membership Application System on our new website. Please CLICK HERE to learn more and apply today!

If you have any questions regarding the application process, please email us at info@pedraresearch.org.

**DO NOT FILL OUT THIS FORM - ENTRIES FROM THIS FORM WILL NOT BE REVIEWED.**

Please select your membership category:

Active - $150 (Investigators and/or clinicians)Affiliate - $100 (PhD scientists, allied health professionals, research coordinators) Trainee - Free (Students, Residents, or Fellows)Community - Free (Parent, Advocate, or Patient over 18)If you're already a PeDRA Member, you don't need to reapply. Please renew your membership on the PeDRA Membership page on our website.

First Name

Last Name

Department/Division

Position

In what year did you complete your training?

ex: 2002

Training Program

Program Director

Program Director Email

Start Date of Training

ex: 2021

End Date of Training

ex: 2024

What year do you anticipate completing your highest level of training including your post-doctoral clinical fellowship?

ex: 2024

Please provide your current position.

Please provide the name and email address of a mentor, supervisor, or other clinician and/or researcher who can serve as a professional academic reference. Please note, that the approval of your application will be delayed if you don't provide this information.

First and last name of reference:

Email address of reference:

Position and institution of reference:

If known, what institution will you be attending for your residency?

If known, what institution will you be attending for your fellowship?

If applicable, what institution will you be moving to as an attending?

Please provide a brief bio about your work in pediatric dermatology.

250 characters maximum

Please provide a brief statement of interest.

Please note, that the approval of your application will be delayed if you don't provide a statement of interest.

Please use this space to share any additional information about why you are interested in joining PeDRA as a Community Member:

Do you wish to receive emails from PeDRA? Please select all that apply.

I’d like to receive the PeDRA Research Bullet monthly e-newsletterI’d like to receive the monthly PeDRA Education Report that highlights PeDRA’s latest educational offerings.I'd like to receive emails to participate in PeDRA member's surveys (not including the PeDRA annual member survey, which you will receive by default).I'd like to receive emails about PeDRA grants, events, and other general programs and opportunities.No, I don't wish to receive any emails from PeDRA outside of information about my PeDRA membership.*

What is your ethnicity?

Hispanic or LatinxNot Hispanic or LatinxI do not wish to provide this information.

Please provide additional information about your Hispanic or Latinx ethnicity.

CubanMexicanPuerto RicanOther Hispanic or Latinx Ethnicity - Write In Below

Other Ethnicity:

Confidentiality Agreement

PeDRA is committed to protecting confidential and sensitive information related to unpublished research ideas, methods data, results, and proposals. <a href="https://pedraresearch.org/confidentiality-agreement/" target="_blank">Click here to view the PeDRA Confidentiality Agreement</a>. Agreeing to the confidentiality agreement is OPTIONAL for PeDRA Members but may be required before participating in certain activities.

By selecting this box I certify that I have read and will abide by PeDRA's Confidentiality Agreement.

Confirmation of Eligibility

Community Membership is available to parents, advocates, and/or patients over the age of 18 who are ineligible for PeDRA membership in any other category and who are not employed by a company that is a current partner of PeDRA or involved in the marketing or development of products relevant to the field of pediatric dermatology. Please use the space below to confirm your eligibility as a Community Member.

By checking this box I certify that I am not eligible to join PeDRA as an Active, Trainee, or Affiliate member.

By checking this box I certify that I am not employed by a company that is a current partner of PeDRA or involved in the marketing or development of products relevant to the field of pediatric dermatology.