Online Membership Form Please fill out the membership form below and submit it. Application Information Your Name* Your Email* Join or renew?* JoinRenew Membership type* Regular Member--$25USUHS--$10 Renewal Directory Changes We have moved to a new sign-up form this year, and we need all members to complete the full application. In future years, renewing your membership will allow you the option to skip the remainder of the form. Member Information Member Title/Rank* (Mr., Ms., Dr., CPT (O-3), CAPT (O-6), Maj (O-4), etc.) Member Phone Number* (XXX) XXX-XXXX Are you yourself a member of the military?* (Your spouse military information can be entered later.) NoYes Member Military Information Member Military Status ---ActiveCivilianRetired Member Military Branch ---USAUSNUSAFUSCGNot Applicable Member Department Examples: "GME","OB/GYN", "Navy Marine Corps Public Health Center", etc. Please leave blank if not applicable. Member Job Title/Area of Responsibility Examples: "Intern", "PGY-3", "Attending", "Resource Management". Please leave blank if not applicable. Spouse/Partner Information Please provide the following information about your spouse or partner. Spouse Name* Spouse Military Status* ActiveCivilianRetired Spouse Branch* USAUSNUSAFUSCGNot Applicable Spouse Rank/Title* (CPT (O-3), CAPT (O-6), Maj (O-4), Mr., Ms., Dr., etc.) Spouse Department* Examples: "GME", "OB/GYN", "Navy Marine Corps Public Health Center", etc. Spouse Job Title/Area of Responsibility* Examples: "Intern", "PGY-3", "Attending", "Resource Management" Additional Information Home Address* Home Address Line 2 City* State* Zip* Additional Phone (XXX) XXX-XXXX Interests BenevolencePlaydatesSocial GatheringsBook ClubCraft ClubBooks4KidsFisher HouseHospitalityVolunteeringDeployment SupportOther Other interests Complete the application When you click Submit, you will be automatically redirected to our payment page.