Membership Application | North American Fetal Therapy Network

NAFTNet Membership Application

Welcome to the North American Fetal Therapy Network (NAFTNet) Membership Page.

Before you begin, you will need the following forms completed at the time of the application submission.

Publication list from all your center's providers (up to the past 5 years)
Society Memberships for the primary and alternate member representative
Personal Statement (Why are you interested in becoming a NAFTNet Member?)
Letter of Support from Current NAFTNet Member (Not Required, Optional)
Disclosure of Conflict of Interest Form (COI) for the primary and alternate member representatives, CLICK HERE
Annual Data Form Pertaining to your Center, CLICK HERE

All the required forms will need to be submitted on the next page.

If you have any questions once you submit your membership application, reach out to the NAFTNet Executive Office, info@naftnet.org.

Membership Dues

Enter Organization Code

Your Dues Rate Type is: General Center Membership $3,000.00

Select an Organization Code

You must create a code that will be used by your employees to join your organization. You will be given instructions at the end of the member application on what information to pass onto your members, and how they can join.

Contact Information

Email *

Re-enter your email *

Prefix

First Name *

Middle

Last Name *

Suffix

Title

Informal Name

Company *

Address Line 1 *

Address Line 2

Address Line 3

City *

State

Zip Code *

Country

Website

Company Twitter URL or Handle

Phone Number *

Fax Number

CCMail

Include me in Membership Directories *
Yes No

Include me in Broadcast Email *
Yes No

Username/Password Username/Password

Please enter the Username/Password you would like to use to login to this website.

Your Username must be unique and must be at least 6 characters.
Passwords must be a minimum of 8 alpha-numeric characters with at least 1 number or 1 letter.

Username *

Password *

Confirm Password *

Additional Information

Center Name (Hospital/University) *

Please attach a publication list or all your center's providers (last 5 years) * Allowed file types: doc,docx,pdf,ppt,pptx,xls,xlsx,txt,gif,jpg,png,jpe

Please attach a list of Society memberships for the primary and alternate representatives * Allowed file types: doc,docx,pdf,ppt,pptx,xls,xlsx,txt,gif,jpg,png,jpe

Please attach a personal statement regarding your interest in NAFTNet membership * Allowed file types: doc,docx,pdf,ppt,pptx,xls,xlsx,txt,gif,jpg,png,jpe

Please attach a letter of support from a NAFTNet member (optional) Allowed file types: doc,docx,pdf,ppt,pptx,xls,xlsx,txt,gif,jpg,png,jpe

Please attach the completed Annual Data Center form. This is a list of all relevant cases seen and treated at your institution in the last year. * Allowed file types: doc,docx,pdf,ppt,pptx,xls,xlsx,txt,gif,jpg,png,jpe

Please attach the completed Conflict of Interest (COI) form: * Allowed file types: doc,docx,pdf,ppt,pptx,xls,xlsx,txt,gif,jpg,png,jpe

* Unless specifically stated otherwise, information discussed and generated in the NAFTNet Executive and Steering Committee meetings, as well as any meeting held under the auspices of NAFTNet, must be kept confidential until a final document or report is issued. Members should not discuss publicly or privately specific details about study proposals or ongoing projects. Confidentiality is necessary to avoid spreading misinformation or release of information that may compromise acceptance from private or public funding agencies for research concepts that have been submitted or are under active review. Until the process of generating a document formulating the NAFTNet position has been completed, the network’s stand on a particular research project or question as it pertains to fetal therapy is subject to change. In addition, NAFTNet positions may have commercial impact and premature release of information could be used by third parties, such as friends and associates of Executive or Steering Committee members, or members of NAFTNet-affiliated committees, for personal benefit.

Payment Details

Payment Method

Enter the name on the bank account according to the information shown on your bank statement. The account number and routing number can be copied from the lower left corner of the check.

Account Type

Checking

Savings

Routing Number

Account Number

Account Holder Type

Business

Personal

Business Name

Account Holder Name

By submitting payment, I am authorizing North American Fetal Therapy Network to initiate a single or recurring ACH/electronic debit in the amount indicated from the bank account I designated above. I understand that this Authorization will remain in full force and effect until the transaction is cancelled by me by contacting North American Fetal Therapy Network, or the ACH/electronic debit is processed from the designated account. I certify that (1) I am authorized to debit the bank account above and (2) the ACH/electronic payment I am authorizing complies with all applicable laws.

Name on Card

Card Number

Expiration

CSC

Billing Street

Billing Zip Code

PO #

Total Amount Due

NAFTNet Membership Application

Membership Dues

Contact Information Contact Information

Username/Password Username/Password

Additional Information Additional Information

Payment Details Payment Details

Contact Information

Additional Information

Payment Details