The Helen Beiser, MD 
Resident Membership Award
 Application Deadline : September 8, 2017

This award is open to child and adolescent psychiatry fellows and general psychiatry residents interested in child and adolescent psychiatry. To apply for the Helen Beiser, MD Resident Membership Award, applicants must complete the following:

- Online application form
- Upload a 300 word or less personal statement regarding your reasons
   for wanting to join AACAP/ICCAP
- Agree to the commitment of attending a minimum of two ICCAP meetings
   per year.

Upon acceptance of the completed application, membership dues for both AACAP and ICCAP will be reimbursed.  New trainee members to ICCAP will be presented at its fall meeting.
 
If you have any questions/concerns, please contact Adrienne Adams, MD
(
Adrienne_L_Adams@rush.edu) or info@iccap.org.

2017 APPLICATION
Note:  All fields with * are required. 
First Name*
Last Name*
Designation (i.e. MD, DO)*
Date of Birth (mm/dd/yyyy)*
Phone (xxx-xxx-xxxx)*
Email Address*
Street Address 1*
Street Address 2
City
State*
Zip Code*
Fellowship Program Name*
Year in Training*
Training Director Name*
Personal Statement (upload)*
Agreement*If selected as a Helen Beiser Awardee, I agree to attending at least two ICCAP meetings annually.    
Today's Date*
e-Signature (enter your name)*
Anti-spam code*