Application Form First Name (required) Last Name (required) Degree (required) Institution (required) Address (required) Address2 City (required) State/Province (required) Zip Code (required) Country (required) Phone Number (required) Fax Email Address (required) Please upload your current CV Do you work at an existing PRCSG center? (required) YesNo If no, please complete the New Center Survey Have you completed Human Subject Protection (HSP) training? (required) YesNo Please upload your Human Subject Protection training document Have you completed Good Clinical Practice (GCP) training? (required) YesNo Please upload your Good Clinical Practice training document Please select your role Full Membership (Physician, Nurse Practitioner or Physician Assistant)Associate Member (Research Nurse, Fellow, Research Professional) Please select your Full Membership rolePhysicianNurse PractitionerPhysician Assistant Your pediatric rheumatology fellowship (for those performing fellowship out side of Canada or US or in adult rheumatology, please see PRCSG bylaws for required additional information). Your involvement in the treatment of children with pediatric rheumatic diseases (e.g. number of days in pediatric rheumatology clinic per week) and approximate number of pediatric rheumatology patients or visits per month or year. Your pediatric hospital including availability of other pediatric subspecialities such as ophthalmology, ICU, etc. For Nurse Practitioner and Physician Assistant applicants, please provide the following documents: Letter of support from a PRCSG member confirming your active involvement in clinical practice or clinical research that has an element related to pediatric rheumatology. Letter of support from a PRCSG member physician working in the same location confirming adequate training in the field of pediatric rheumatology. Standard of care arrangement document (or other document as per state laws) with one or more PRCSG physician members in a PRCSG Clinical Center. Please select your Associate Member rolePediatric Rheumatology FellowResearch NurseResearch Professional Research Rheumatology FellowPlease provide the following document: Letter of support from fellowship program director confirming you are currently in a pediatric rheumatology fellowship program or a medicine pediatrics resident in a combined adult and pediatric rheumatology fellowship. Research NursePlease provide the following documents: Letter of support from a PRCSG member physician working in the same location confirming adequate experience of at least 2 years in the field of pediatric rheumatology. Letter of support from a Full PRCSG member confirming active involvement in clinical research that has an element related to pediatric rheumatology. Research Professional (Master’s degree or higher in a research-related field)Please provide the following document: Letter of support from a Full PRCSG member confirming active involvement in clinical research that has an element related to pediatric rheumatology.
