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:*  
Street Address 1:*  
Street Address 2:
Zip/Postal Code:*  
Phone Number (777) 777-7777:  
Date of Birth:(MM/DD/YYYY)*    
Gender Identity:
Do you identify as transgender or gender non-conforming? :
Are you Spanish/Hispanic/Latino?

Ethnicity/Race (check more than one if applicable.):

Medical School Information
Medical School:*  
Zip/Postal Code:*  
Date Entered Medical School:*
Expected Date of Graduation:*  
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.