PICS Society Membership Application
The PICS Society is the global community of doctors, nurses & allied health professionals (AHPs) dedicated to minimally invasive treatment of congenital heart disease (CHD). All candidates:  please complete & submit this form then email your CV to membership@CHDinterventions.org.  Membership categories:
  • FELLOW (FPICS): Physician who completed training at least one year ago and has performed 100 interventions post-training: apply for PICS Fellowship (FPICS):  Also ask a colleague to email us a short reference letter.  
  • MEMBER: Physician who completed CHD training less than one year ago and has performed fewer than 100 interventions post-training: apply for PICS Member.  Nurse, technologist or other AHP whose duties relate to minimally invasive treatment of CHD (e.g., pre-procedure tests/prep, cath lab, post-procedure, teaching, clinic, etc.):  apply for PICS Membership.
  • FELLOW-IN-TRAINING (FIT): If you are in or have been accepted into a CHD Interventional fellowship program, your membership will be FREE during training. Please email two documents to membership@CHDinterventions.org: your CV, and a letter from your training program director confirming the start/end dates of your fellowship.
  • NURSE, TECHNOLOGIST OR OTHER AHP: Those whose duties relate to minimally invasive treatment of CHD (e.g., pre-procedure tests/prep, cath lab, post-procedure, teaching, clinic, etc.):  apply for PICS Membership. 
Dues:  No dues payment today.  We will invoice you after your application has been reviewed.
  • Annual dues for physicians: $200 USD plus one-time $25 administrative fee (North America); $50 USD plus one-time $10 admin. fee (all other nations).
  • Annual dues (discounted) for nurses/techs/AHPs: $50 USD (North America; no admin. fee); $15 (all other nations; no admin. fee). 
  • If you are in training:  no dues while in training.
Please note:  
  • Your responses on this form will be automatically saved after each keystroke (there is no "save" button). 
  • Ensure your CV notes your involvement with CHD minimally invasive treatment.  
  • Nurses and technologists: to learn about our Nurses & Allied Health Professionals activities click HERE.  
  • Want to know more ?   Click HERE for general information or email membership@chdinterventions.org    
Sign in to Google to save your progress. Learn more
Email *
First name/given name *
Middle name or initial
Last name/surname/family name *
Suffix (Jr., Sr., Filho, III, other)
DEGREE(S) *
Click ALL THAT APPLY:
Required
Your professional title(s) *
Your primary institution name, and (if any) department  *
Institution city or town *
Institution country *
Select ONE
Name and email of your administrative assistant (if any)
Interventional doctors only:  month and year completed (or will complete) your interventional training
Nurses, technologists and other allied health professionals only:  month and year completed (or will complete) your training
Nurses, technologists and other allied health professionals only:  your primary field(s) (e.g., nursing, echo tech, ekg tech, nurse practitioner, physician assistant, cath lab tech, etc.)
Interventional physicians only:   APPROXIMATELY how many interventional procedures have you done since you completed your training ? (click ONE)
Clear selection
*Please note:  If you select "FPICS" below, you are attesting that you (1) completed your interventional training one year or more ago and (2) have performed at least 100 minimally invasive congenital heart procedures as 1st operator (post-training).   *
If you are applying for PICS Fellowship (FPICS designation, your profession's highest level of recognition), please provide a reference letter from a colleague or mentor in support of your application or give us the name and email address of a colleague, supervisor, or mentor if you prefer we contact them directly.
Online Directory Opt-Out Notice:  All PICS Society nurse & allied health professional members (NAHPs) can be listed in the PICS NAHP membership directory on www.CHDinterventions.org  This online directory includes name, degree(s), institution and country, but NO contact information.   
  
NAHPs:  Click ONLY if you do NOT want to be included in this directory (all other applicants skip this question).  
NOTE: All PICS Society members receive Pediatric Cardiology Journal, Congenital Cardiology Today, and enrollment in the PICS/CCISC DocMatter Community.  Your enrollment is automatic.

These will begin once your application is approved. We will provide your name and email to these 3 partner organizations, who are prohibited from sharing your name or email address. Questions?
Please email: membership@CHDinterventions.org
Would you like PICS to contact your designated reference on your behalf to obtain a letter of reference ?
Clear selection
Would you like to nominate your nursing, technologist and/or physician colleagues to join PICS ?  If yes, include their name(s) and email address(es) here: 
FINAL STEPS 
  • Press the "Submit" button just below.
  • Email your curriculum vitae (CV) to membership@CHDinterventions.org
  • FPICS candidates please ask a colleague to email us a letter of support.
We will contact you if we need further information.
Questions?  Email membership@CHDinterventions.org
THANK YOU for your application and for all you do for your patients & their families !
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms