American Geriatrics Society Student Application for E-Membership

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* 1. Full Name of Applicant

First

Last

Middle Initial

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* 2. Date of Birth

MM/DD/YYYY

Date

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* 3. Address

Street Address

City

State

Zip

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* 4. Preferred Email Address

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* 5. Phone Number (include area code):

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* 6. Student Type

Undergraduate Medical Program

Undergraduate Nursing Program

Graduate Nursing (Full-time) Program

Graduate Nursing (Part-time) Program

Undergraduate Pharmacy Program

Other Graduate (Full-time) Program

Other Undergraduate (please specify)

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* 7. School Information

Name of School

City

State/Province

Matriculation Date

Anticipated Graduation Date

Faculty Advisory Name

Faculty Advisory Email

Anticipated Degree

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* 8. Anticipated Next Step After Graduation

Residency

Graduate Education

Employment

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* 9. In order to process your membership we will need a copy of your student ID or matriculation letter. You can either upload the file here, or email a copy to membership@americangeriatrics.org for verification.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 10. I affirm that I am currently enrolled

FULL-TIME in an UNDERGRADUATE medical, nursing, pharmacy or other healthcare program and that the information provided above is true to the best of my knowledge.

PART-TIME or FULL-TIME in a GRADUATE nursing program, am not currently employed as a nurse and that the information provided above is true to the best of my knowledge.

If you are currently employed as a nurse and have returned to school to further your education, you qualify for our discounted "Recognized Healthcare Professional" category at www.americangeriatrics.org/join .

FULL-TIME in a non-nursing GRADUATE program and that the information provided above is true to the best of my knowledge.

If you are enrolled part-time and are working full-time in a health career then you should apply for a different membership category at www.americangeriatrics.org/join .

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* 11. I affirm that the information provided above is true to the best of my knowledge:

E-Signature

Date