Application for Membership


Thank you for recognizing the importance of supporting your local dermatology community and applying for membership in the Washington State Dermatology Association.  Your participation and financial support is essential as we continually strive to strengthen our organization.

WSDA Membership Categories

Active Member: A physician who is licensed to practice medicine, has completed formal residency training in dermatology and who has been certified or is eligible to be certified by the American Board of Dermatology.

Affiliate Member: Other licensed health care providers who have additional training in the practice of dermatology. Affiliate members are ineligible to vote or hold office.

Junior Member: A physician who is licensed to practice medicine, and is engaged in a dermatology residency training program, or who has satisfactory completed such a training program and in engaged in a dermatology fellowship training program. Junior members are ineligible to vote or hold office.

Emeritus Members: A previous active members who has continued membership in the association for a minimum of 10 years and who has reached the age of 70. Emeritus members are ineligible to vote or hold office.

Contact Information

Name:*
Title:
Home Address:
Home Phone:
-
Home E-mail:
Practice Name:
Practice Address:
Practice Phone:
-
Practice E-mail:
Practice Website:
Practice Manager Name:
Practice Manager Phone:
Practice Manager Email:
Preferred address for WSDA correspondance:

Education: (School Name/Location and Years Attended)

Medical School:
Residency:
Fellowship:
Board Certification:
Board Eligible:

Subspecialties (for membership directory) Please check all that apply

Cosmetic Procedures:
Lasers/Light Therapy:
Surgery:
General Dermatology and Additional Interests/Procedures:
Is your practice open to new general dermatology patients?
Is your practice open to new cosmetic patients?

Membership Dues Payment

Active - $150
Affiliate - $75
Junior - $0
Emeritus - $0

Membership Dues:*
Total:
Please verify:

Upon completing the form and clicking "submit," if any funds are due to complete the application for membership, you will be directed to PayPal to make the payment.  You do not need a PayPal account to make a payment.

INQUIRIES

Contact Becky Constantine, Association Executive, at the WSDA Office at (206) 956-3635 or (800) 552-0612 Ext. 3018 or send emails to admin@washingtonderm.org.