Medical Student Membership Application

Prior to submitting your on-line medical student application, please obtain the name and e-mail of an employee at your medical school who can verify your enrollment (e.g. Clerkship Director, Dean of Students, Registrar, Department of Psychiatry Chair, or Faculty.) This information is required for membership and will need to be entered at the end of this application.

Biographical Information
APA Promotion Code (if applicable):
First Name:*  
Middle Name:
Last Name:*  
Suffix:
Email:*    
Street Address 1:*  
Street Address 2:
City:*  
State/Province:*
 
Zip/Postal Code:*  
Country:
Phone Number (777) 777-7777:  
Date of Birth:(MM/DD/YYYY)*    
If you reside in the European Economic Area please do NOT respond to this question.
Gender Identity:
If you reside in the European Economic Area please do NOT respond to this question.
Do you identify as transgender or gender non-conforming? :
If you reside in the European Economic Area please do NOT respond to this question.
Are you Spanish/Hispanic/Latino?



If you reside in the European Economic Area please do NOT respond to this question.
Ethnicity/Race (check more than one if applicable.):









Medical School Information
Medical School:*  
City:*  
State/Province:*
 
Zip/Postal Code:*  
Country:*  
Date Entered Medical School:*
Expected Date of Graduation:*  
Local District Branch Communication Opt-In
  I hereby opt-in to allow APA to share my name, contact information (including email address, phone number, and mailing address) and my medical school name with start and end dates with the District Branch in whose jurisdiction my medical school is located. In making this selection, I understand that the District Branches are separate entities from APA and their use of my information will be governed by their own privacy policies.

Agreement
Please accept my application for Medical Student Membership in the American Psychiatric Association. If my Medical School is based outside the United States or Canada, it will be an International Medical Student Membership. I understand that I am eligible for APA Medical Student or International Medical Student membership as long as I am enrolled in an accredited medical school.