Membership Form

Resident/Fellow

Membership Options

Founding Member - $1000+
Membership tier for those wishing and able to make a significant contribution to the organization, fueling our mission and vision.

Sustaining Member - $500-999
Membership tier for those wishing and able to offer additional financial support to the organization, fueling our mission and vision.

BMDF Member - $25
Full membership in the organization, with all membership privileges.

Membership Dues (see options above)

Amount

Type of Donation

Recurring DuesOne Time Dues

Frequency

Contact Information

First Name

Last Name

Preferred Name

Address

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

International Phone

Email (please do not use .edu addresses)

Additional Information

Undergraduate Institution

Professional/Graduate Institution

Professional/Graduation Institution Graduation Year

Residency Institution

Residency Completion Year

Professional Degree

Pre-Professional Category

Medical Specialty

Other specialty or sub-specialty

Place of Worship (please include name, city, state, country)

Area of Ministry Interest

Area of Ministry Interest 2

Other areas of interest

What other information would you like BMDF to know about you?

Help Us Cover Costs

Simply leave "Yes!" checked below to ensure that 100% of your intended donation is available for our mission.

Yes! I want $0.00 to go to Baptist Medical Dental Fellowship and I will donate $0.00.No. I will donate $0.00 and Baptist Medical Dental Fellowship will cover the processing costs.

Payment Information

Payment Options

Credit Card Information

Card Holder Name

Card Account Number

Expiration Date

Security Code

Billing Address

Same As Above

Address

City

State/Province

Zip/Postal Code

Privacy Policy
We take precautions to protect your information. We collect credit card or bank account information, names, addresses, and other data related to your transaction when you make a payment through our site. We use this information to process your payment.

Terms/Conditions
By submitting your payment, you authorize us to charge the account above for the amount specified in the Transaction Amount field. Account information for Recurring Pledges/Monthly Giving is encrypted and stored securely via SafeSave™ for automatic processing of your future payments. Notify us at anytime if you wish to discontinue your pledge.