Student Membership Opt-in Form

Thank you for your interest in joining APMA! We look forward to being of service. APMA Membership is FREE for students! Please complete the form below to activate your membership.

CONTACT INFORMATION

	First Name
	Middle Name
	Last Name
	Previous Last Name
		(changed due to marriage, divorce, etc.)
	Nickname
	Mailing Address
	Apt. #
	City
	State
	Zip
	Cell Phone
		APMA does not share cell phone or email addresses.
	Email Address
	Date of Birth
		Month, Day, Year (For statistical purposes only.)
	Gender
		For statistical purposes only.
	Ethnicity
		For statistical purposes only.

EDUCATION

	Podiatric Medical College	Barry University California School of Podiatric Medicine at Samuel Merritt University Des Moines University Kent State University Lake Erie College of Osteopathic Medicine School of Podiatric Medicine Midwestern University New York Scholl College at Rosalind Franklin University Temple University University of Texas Rio Grande Valley Western University
	What year will you graduate?
	Join your state component organization. It's free!	Yes No
		Allow APMA to forward your information to the component in the state where your school is located by clicking "Yes" above.

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