Institutional
Membership Application

After completing this application for your institution, submit the Affiliated Staff Application for each of the staff you'd like to register as society members, or forward the link to your Affiliated Staff to complete.
So that your Member Institution can be featured properly, please forward the following to cnoc@cardiacneuro.org: a vectored eps logo for your institution or specific program and the link to the program you wish to highlight.

INSTITUTIONAL INFORMATION

Institution
Institution City
Institution State
Billing Address
Billing Contact
Title
Work Phone
Work Ext
Email

CNOC DATABASE

Clinical Lead for CNOC
Title
Work Phone
Work Ext
Email
Administrative Contact
Title
Work Phone
Work Ext
Email
Data Entry/Collection
Title
Work Phone
Work Ext
Email

MEMBERSHIP INFORMATION

Your institution's total CNOC dues are based upon whether your institution participates in CNOC’s Clinical Registry.
	My institution participates in CNOC's Clinical Registry. The annual CNOC dues total $8,000, which consists of $3,500 dues paid to CNOC, a $2,000* payment to the CNOC Data Coordinating Center at the University of Michigan, and a $2,500^ payment to Arbor Metrix, the host of CNOC's data reporting platform.
	My institution does NOT participate in CNOC's Clinical Registry. My CNOC dues total $5,500, paid to Cardiac Neurodevelopmental Outcome Collaborative (CNOC).
PLEASE NOTE: So that your Member Institution can be featured properly, please forward to cnoc@cardiacneuro.org a vectored eps logo for your institution or specific program and the link to the program you wish to highlight. *On July 1, 2024, the Data Coordinating Center at the University of Michigan increased its annual fee to $2,500. CNOC members are invoiced separately by University of Michigan for that portion of CNOC dues. ^Beginning in July 2025, Arbor Metrix will increase its annual fee to $2,750 (and in July 2026 to $3,000). CNOC members are invoiced separately by Arbor Metrix for that portion of CNOC dues.

PAYMENT INFORMATION

Card Type
Name printed on card
Card Number
Security Code
Expiration Date	/
Card Address
Card Zip Code

Electronic Signature
If you do not receive a confirmation e-mail from the CNOC office within 14 days of submitting your registration form, please call the office to confirm that your registration material has been received.

Copyright © · Cardiac Neurodevelopmental Outcome Collaborative

2209 Dickens Road, Richmond, VA 23230-2005
Phone: 804-565-6397 · Fax: 804-282-0090 · Email cnoc@cardiacneuro.org
View Privacy Policy