Medical Student Membership 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:*    
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. I understand that I am eligible for APA Medical Student membership as long as I am enrolled in an accredited U.S. or Canadian medical school. If, upon graduation, I have chosen to enter an approved psychiatric residency training program, I will then be eligible to apply for membership as an APA Resident-Fellow Member. My signature indicates that I agree to abide by the Bylaws of the APA; as well as the procedures outlined in the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, that APA may publish my membership data to its members, license or sell my name, address, phone number and/or e-mail to third parties, and provide government authorities all information pertaining to me if in receipt of a subpoena from authorities. I will hold APA harmless from any and all liability arising out of or relating to my membership, including but not limited to, decisions concerning membership, ethics, and/or the provision or storage of my personal and/or financial information. Any disputes that arise out of or relate to this Agreement and/or my membership shall be governed by Virginia law without regard to its choice of law principles and any hearings or proceedings shall be heard in the state of Virginia; and I pledge myself to the highest standards of ethical practice and conduct.