APA Promotion Code (if applicable):
First Name:*
Middle Name:
Last Name:*
Suffix:
Email:*
Street Address 1:*
Street Address 2:
City:*
Zip/Postal Code:*
Country:
Phone Number (777) 777-7777:
Mobile Phone Number (777) 777-7777:
Date of Birth:(MM/DD/YYYY)*
Country of Birth:*
Medical School:*
City:*
Zip/Postal Code:*
Country:*
Date Entered Medical School:*
Expected Date of Graduation:*
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.
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.