I hereby release from liability all representatives of the Ohio Dermatological Association for their acts performed in good faith, without malice and in reasonable belief that any information gathered or exchanged is warranted by the facts known to them.

I understand and agree that this release and consent is irrevocable. I understand and agree that I, as an applicant for membership, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics and other qualifications for membership.

I agree to return my certificate of membership if my license/certificate to practice as a Physician Assistant or Nurse Practitioner “in any state” is revoked, suspended, or limited beyond its present state, or if my membership is revoked for such other causes as may be placed legally in the bylaws of the Association.

I understand that if I cease to be employed by a Fellow or Associate member of the ODA, I shall be automatically dropped from the roll of the Corporation. I shall immediately be eligible for membership if employed by a Fellow or Associate member of the ODA in the future but must pay a new membership fee.

I acknowledge responsibility for my membership dues.