Scientific Membership Application

Complete Instructions (pdf)
Identifying Information  
Name *: M.D.: Ph.D.: B.S.: Other:
Faculty Appointment: (if applicable)  
School: Department: Rank:
Organizational Affiliation: (if applicable)  
LURIE: NU: NMH: ENH: VALMC: RIC: Other:
   
Contact Information  
Campus Address*:
Mailing Address: Office Phone*: -
Room # Lab/Other Phone: -
City State ZIP Fax: -
Internet/E-mail Address:
Applying for*: FULL Membership: ASSOCIATE Membership: For Definitions
   
Please choose up to two Programs or Centers that best suit your interests, indicating which is primary, or choose non-programatically aligned when there is no appropriate program match. Program/Center Listings

Please provide a brief statement regarding your primary basic science and/or clinical research interests and activities:

Have you submitted a grant or Institutional Review Board proposal through the Research Center in the past 12 months? If so, please describe agency, title and your role in the project:


Please describe your participation in other Research Center-related interest or activities:
   

* Required Field

To be considered please send or email a copy of your NIH Biosketch or a brief resumé to Peg Rainey, Children’s Hospital of Chicago Research Center, 225 E. Chicago Avenue, Box 205, Chicago IL 60611 or prainey@luriechildrens.org.