OPPA Medical Student Membership Application

Please provide the following information to apply to become a member of OPPA

OPPA membership is open to only students attending a medical school in Ohio.

PERSONAL INFORMATION

First name
Middle name
Last name
Suffix
Birthdate
Gender Identity

CONTACT INFORMATION

School Email Address
Personal Email Address*
Mailing Address
City State Zip
Home Phone Mobile Phone
*Please provide both your institution email and an email address for you that is not associated with your institution. We want to make certain you receive important emails and many institutions have fire walls that block our communication.

EDUCATION

Medical school attending
Date entered medical school
Expected date of graduation
Which specialties are you considering? Rank in order.
1)
2)
3)
4)
What area of psychiatry are you interested in?(check all that apply):
General Psychiatry
Forensic Psychiatry
Child and Adolescent Psychiatry
Addiction Psychiatry
Consultation-liaison Psychiatry
Geriatric Psychiatry
Other (please list below)
Other
Are you a member of APA?(membership is separate for OPPA and APA – you may wish to join both for full membership benefits)
If you are not already a member of APA, would you like to “opt-in” for OPPA to share your contact information with APA?
Please accept my application for Medical Student membership in the Ohio Psychiatric Physicians Association (OPPA). I understand that I'm eligible for OPPA Medical Student membership as long as I am enrolled in an accredited medical school in Ohio.
Signature
Date ?
   - denotes required fields