Membership Application
Apply Today!
• YOUR SOCIETY: BY and FOR the Global Congenital Heart Disease (CHD)
Interventional Community• OUR GOALS: Education, Quality, Advocacy, and Leadership• OUR VISION: A world where anyone who can benefit from minimallyinvasive techniques to treat CHD has access to safe, effective care.

Please complete this two-page form on your computer (this is an editable pdf form) then save your file. N e xt, e mailthe form to membership@CHDinterventions.org. You do not need to provide the other necessary documents today(described on next page); our Membership Department will assist you as necessary. Thank you.
Last Name __________________________________________________ First Name ________________________________________________________
Title _______________________________________________________ Institution ________________________________________________________
Address ______________________________________________________________________________________________________________________
City _______________________________________________________ State/Province _____________________________________________________ZIP/Postal Code _____________________________________________ Country __________________________________________________________E-mail _____________________________________________________ Phone ___________________________________________________________
Month/Year finished training ____________ Approximate number of interventional procedures after training (FPICS candidates only) ___________

Membership Dues (12 months dues plus one-time processing fee). See next page for qualifications.
FELLOW (FPICS)
Experienced MD, Scientist,
Nurse/Allied Health Professional

MEMBER
Physician or Scientist;
Training completed

MEMBER
Nurse/Allied Health Professional

FELLOW-IN-TRAINING
In fellowship program$0 (Now in training)$0 (Accepted into training)

Payment Payment can be made with Visa, Mastercard, American Express or Check. If you prefer a different method, please contact
membership@CHDinterventions.org
VisaMasterCard

American Express

Card # _______________________________________________ Exp. Date ______________

Card Holder Name ________________________________________________________________________________________________________
Check (Please make checks payable to The PICS Society, and MAIL TO: M. Wallig, Attn. PICS Membership, 10151 Avenue N, Chicago, IL 60617 USA

See next page for membership criteria and required documentation.
Rev. 04/06/2022

Membership ApplicationMembership Categories and Required Documents

YOUR NAME _______________________________________________CATEGORY #1: FELLOW (FPICS)

CATEGORY #2: MEMBER

Becoming a PICS Society Fellow is our profession’s highest mark ofdistinction. The FPICS designation after your name and the FPICS
diploma recognizes those who show deep experience in the fieldof minimally invasive treatment of congenital heart disease. Pleaseemail three documents to membership@CHDinterventions.org:

Members serve vital roles in the PICS Society, receiving benefits
and representing numerous medical & scientific disciplines.
See our website for details. Please email two documents tomembership@ CHDinterventions.org:

1. This completed two-page application form.
2. Your professional resume.
3. Ask a colleague or supervisor to email us a reference letter on
your behalf. The letter should additionally attest that you have
performed at least 100 minimally invasive congenital heartprocedures (post-training) as 1st operator.
Note: FPICS eligibility requires 1 years’ experience following completionof training. If you have less than 1 years’ experience as 1st operator, apply
as a “Member” (Category #2 ) and we will contact you once you meet theexperience milestone.

1. This completed two-page application form.
2. Your professional resume.

CATEGORY #3: 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 three documents to membership@CHDinterventions.org:
1. This completed two-page application form.
2. Your professional resume.
3. A letter from your training program director confirming the start/end dates of your fellowship.

The PICS Society has many Volunteer Opportunities. Please tell us a little about yourself:“I am interested in the following areas”(CHECK ALL THAT APPLY):

Adult CHD

Fundraising

Online Professional Education

Research

Budgeting/Admin

Global Partnerships

Patient Advocacy

Simulation Technology

Clinical Guidelines

Industry Relations

Physician Certification

Social Media

Early Career Development

Member Recruitment

Public Education

Lab Accreditation

Educating the Next Generation

Nursing, Allied Health

Quality Improvement

Educational Seminars

Professionals

Regulations & Reimbursement

Other Interests (briefly describe): What is the single most important goal the PICS Society can accomplish for YOU?
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Opt-Out Notice: PICS Society member physicians/scientists receive three members-only benefits at no additional charge: (1) membership in thePICS/CCISC DocMatter Community (an online, peer-to-peer collaboration platform for CHD interventionalists globally); (2) online subscription to Pediatric
Cardiology Journal (the official PICS Society Journal); and (3) subscription to Congenital Cardiology Today (CCT, the PICS Society’s official news andinformation source). If you do not wish to receive these free membership benefits, check HERE

Please return this completed form via email to membership@CHDinterventions.org

OUR MISSION
Gobally promoting the highest quality of care for children and adults with congenital heart disease (CHD), through minimallyinvasive cardiovascular techniques. The Society partners with the congenital interventional community to further theknowledge and skills of all involved in the specialty, and to foster research and advocacy on behalf of patients worldwide.
Rev. 04/06/2022