1. Request for Information

The AAP has a variety of program materials that may be of interest to you. Please indicate which programs you would like to receive information about by checking the appropriate boxes below. Your name will be added to the appropriate mailing list or electronic mailing list.

Breastfeeding Promotion in Physicians’ Office Practices
Breastfeeding Initiatives
Childhood Immunization Support Program
CATCH (Community Access to Child Health) Program
Community Pediatrics Training Initiative
Provisional Section on Early Education and Child Care
Healthy Tomorrows Partnership for Children Program
Medical Home Initiatives for Children with Special Needs
Medical Home Training Program
Mental Health Initiative
Native American Child Health Program
Oral Health Initiative
Surveillance and Screening Initiatives

2. Would you like to receive information about becoming a member of the following groups?

	The American Academy of Pediatrics
	AAP Chapter Membership in your state
	Section on Breastfeeding
	Council on Children with Disabilities
	Council on Community Pediatrics - Indian Health Special Interest Group - Prevention and Public Health Special Interest Group - Community Pediatrics Education and Training Special Interest Group - Section on Early Education and Child Care - Rural Health Special Interest Group
	All of the above

3. Would you like to be placed on the AAP Community Pediatrics contact list to receive the CATCH Quarterly and periodic electronic and mail announcements regarding funding opportunities, department activities and events?

	Yes
	No, I prefer only to have my interests documented and to receive the information I have requested above.

4. Contact Information (preferred mailing & e-mail address): (To receive the CATCH Quarterly, please complete mailing address)

First Name:
Middle Initial:
Last Name:
Degrees:
Title:
Organization:
Address:

City:
State:
Zip:
Telephone:
Fax:
Email:	(Required)

Note: You may be removed from the AAP Community Pediatrics contact network or database at any time. Please send your request:

by e-mail to docbi@aap.org
by phone at 847/434-7085
or by writing to the address listed below:

AAP Department of Community Chapter and State Affairs
Attn: DOCBI Coordinator
141 Northwest Point Blvd.
Elk Grove Village, IL 60007

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