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Utah Thoracic Society Membership Application

:

$50 Full Membership
Free Trainee Fellow, Resident, Student

 

(*Utah Thoracic Society members are not required to be a member of its parent organization - the American Thoracic Society. Elected Officers of the Utah Thoracic Society must be members of the American Thoracic Society)

 

Section 1: Demographic Information

Last Name *
First Name *
Middle Name
Organization:
Address *
City *
State *
Zip Code *
Daytime Telephone *
Fax Number
EMail *
Education
MD   DO   PA   NP   RCP   RN   PhD   PharmD   Other:
Primary Board Certification
Secondary Board Certification
Subspecialty Board

 

Section 2: General Information

(Check all that apply)

Work Setting:
Academic Practice
Private Practice
Retired
Government
Industry
Other

If Other:
As an UTS member, would you like to be on a list which we share with the public requesting a membership listing? *
Yes   No  
As an UTS member, please check which areas you would like to participate:
Advocacy
Research (mentor or collaborate with colleagues)
Educational sessions and meetings
Networking

 

Section 3: Areas of Interest/ Expertise

This will help us to understand and fully represent our members. *
Allergy/Immunology
Asthma
COPD
Critical Care Medicine
Cystic Fibrosis
Infectious Diseases
Interventional Pulmonary
Interstitial Lung Disease
Lung Cancer/Oncology
Environmental/Occupational Medicine
Palliative Care Medicine
Pathology
Pediatrics/Neonatology
Pulmonary Hypertension
Radiology
Reactive Airway Disease
Sleep Medicine
Tobacco
Transplant Medicine

 

Are there any specific areas or topics that you would like to see covered in educational sessions?

 

THE UTAH THORACIC SOCIETY

The Utah Thoracic Society (UTS) is a non-profit professional and scientific society dedicated to lung health including pulmonary, critical care, sleep medicine, and public health. Our mission is to further medical education, scientific collaboration, and to promote advocacy for issues relating to lung health in the state of Utah. The Society is a state chapter of the American Thoracic Society and will work closely to support its parent organization. We represent academic and community physicians, trainees in pulmonary and critical programs, pulmonary allied health professionals, and other professionals involved in lung health.

 

Section 4: Application

I hereby apply for membership in the Utah Thoracic Society:
(Full Name Signature)
Please credit the UTS member who urged you to join the Society:
Please indicate other professionals (and email address) you would recommend for UTS membership: