METROPOLITAN DC THORACIC SOCIETY
MEMBERSHIP APPLICATION
PLEASE PRINT OR TYPE ALL INFORMATION
Check one: ____ New Application
$60
Free
____ Renewal of Membership
ACTIVE –
Attending M.D. Ph.D.
ASSOCIATE – Fellow, Postdoctorate,
RN, PA, RRT
SECTION 1: Demographic Information
Name _____________________________________________________________________________________________
Last
First
Middle
Present Position ___________________________________________________________________________________
Address __________________________________________________________________________________________
City ___________________________________________ State ______________ Zip Code ________________________
Daytime Telephone (____)_____________ Fax Number ( ____) _______________ EMail______________________________
Education: ____ M.D. ____ D.O. ____ R.N. ____ M.N. ____ R.C.P. ____ Ph.D. (Area of Interest) ____________________
Board Certification:
Primary ___________________ Secondary_____________________ Subspecialty Board _____________
SECTION 2: General Information (all applicants)
SECTION 3A: Physician Information
Please check as many areas as you are willing to serve in an
advisory capacity.
Please indicate any areas in which you have special
interest or expertise.
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Adult Asthma
Pediatric Lung Disease
Chronic Lung Disease
Environmental/Occupational Health
Home Health
Influenza/Pneumonia
Smoking
Sleep Apnea
Tuberculosis
Within that advisory group, in which areas would you feel
comfortable being called upon?
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Advocacy (testify on legislation)
Public relations (speak to media)
Education of medical profession (conferences, grand
rounds, etc.)
Education of lay audiences (patient ed. programs,
support groups, etc.)
Assist in evaluating, revising, promoting education
pieces
Submit articles for publication in newsletter
Please indicate if you are interested in serving on the
MDCTS Executive Committee.
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Allergy/Immunology
Cardiovascular Disease
Chronic Lung Disease
Critical Care
Cystic Fibrosis
Infectious Diseases
Internal Medicine
Interstitial Lung Disease
Lung Cancer/Oncology
Occupational Medicine
Pathology
Pediatrics/Neonatology
Radiology
Reactive Airway Disease
Sleep Apnea
Other ___________________________________
Present Work Setting:
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Institutional Practice
Private Practice
Research
Medical School Faculty
Retired
As a MDCTS member, would you like to be on a list which
we share with the public requesting a physician listing?
____ YES
____ NO
- Over -
SECTION 3B: Nurse Information
The criteria for membership is an advanced degree in nursing with an interest in the prevention and management of respiratory conditions
or an RN with a minimum of one year experience in a respiratory nurse specialist area.
My expertise is in the following area(s):
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Critical Care
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Ambulatory Care (office, clinic practice)
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Adult Care
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Pediatrics
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Home Care
Long Term Care
Nursing Education
Public Health
Other ______________________________________
SECTION 3C: Respiratory Care Practitioner Information
The criteria for membership is Certified Respiratory Care Practitioner in the District of Columbia with at least three years full-time
experience as an RCP. (Experience does not have to be in DC)
My expertise is in the following area(s):
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Critical Care
Pediatric/Neonatal Intensive Care
Pulmonary Function Testing
Home Care
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Management
Education
Other ______________________________________
THE METROPOLITAN DC THORACIC SOCIETY
The Metropolitan DC Thoracic Society (MDCTS) is a professional organization dedicated to all aspects of lung disease, with special
attention given to research, professional education for pulmonary critical care academic and community, physician pulmonary critical
trainees and pulmonary allied health professionals (e.g. Nurses and respiratory therapists) and clinical practice.
The functions of the Metropolitan District of Columbia Thoracic Society are:
 to disseminate the latest information regarding the diagnosis and treatment of pulmonary diseases
 to expose physicians to a variety of topics related to pulmonary health care
 to encourage the highest standards for training in pulmonary medicine and clinical practice
 to foster knowledge exchange and open discussion among the local pulmonary community
 to facilitate research within the region and interpretation of new scientific research
SECTION 4: Application
I hereby apply for membership in the Metropolitan DC Thoracic Society:
_________________________________________________________________________
Signature
Date
Please credit the MDCTS member who urged you to join the Society: ________________________________________________
Please indicate other professionals you would recommend for MDCTS membership:
________________________________________________________________________________________________________
Return completed application and dues payment to:
Mail: American Thoracic Society
Attn: MSCR Dept.
25 Broadway 18th Fl
New York, NY 10004
Email: chapters@thoracic.org
Please charge my:
 Visa
Account Number:
___________________________
Exp. Date:
(212) 315-8651
 Amex
_______________________
_______________________________________
Please print your full name, as it appears on your card.
Signature
Fax:
 MasterCard
________________________________
 My check is enclosed payable to American Thoracic Society