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Medical Student Membership Application
Prior to submitting your on-line medical student application please obtain the name and e-mail of your institutions Psychiatry Department Chair. This information is required for membership and will need to be entered at the end of this application.
My application is being submitted in response to your Member-Get-A-Member campaign. I am being referred by:
Member Name:
His/Her Member ID:
Member E-mail:  
Biographical Information
APA Promotion Code here:
After making a selection, using a drop down menu, be sure you tab out before advancing to the next data field.
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)*    
Gender:

Medical School Information
Medical School:*
City:*  
State/Province:*  
Zip/Postal Code:*  
Country:*
Date Entered Medical School:(MM/YYYY)*
Expected Date of Graduation:(MM/YYYY)*  

Endorsement
Chair, Department of Psychiatry/Faculty
Full Name:  
APA Member Id:
Email:  
Medical School:  
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 Member-in-Training.

My signature indicates that I agree to abide by the Bylaws of the APA; I will hold APA members, officers, employees, and agents free from all damage and complaint by reason of any action taken on this application, or by reason of any subsequent action on membership; and I pledge myself to the highest standards of ethical practice and conduct.  
     

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