IPBIS Membership Form

 

Fill out the information below to join International Pediatric Brain Injury Society (IPBIS).  Bolded fields are required. 

Please note that the membership fee of $300 includes IBIA Full Membership for $250 and a IPBIS Membership for $50. 

For a list of IPBIS benefits, please click here

Gender

Section 1. User Information

Salutation
First Name/ Given Name
Last Name/ Last Name
Email
Company/Institution
Phone
Mailing Address
Mailing Address (Continued)
City
State/Province
Zip Code/Postal Code
Country
Fax
Primary Focus
Clinical Interests
Research Interests
Referral Source Member Number
Membership Type

Section 4. Payment Method

Payment Method

Section 5. Join User Groups

User Groups

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