Wisconsin Medical Society Student Membership

Student Membership

Submit the form below for Wisconsin Medical Society membership.
School *
Student Name *

First Name Middle Name Last Name
Birth Date *

Month Day Year
Address while you are at school *

Street Address

City State / Province

Postal / Zip Code
School Email *
example@example.com
Non-School Email *
example@example.com
Phone Number *
White Coat Thank You

The Wisconsin Medical Society Foundation is pleased to have provided your very first white coat. When you received your white coat, you should have also received a personal note of welcome from the physician who sponsored your coat. Please submit a photo of you in your white coat and a message below that will be sent to that physician as a thank you. If you prefer, you may email your photo and thank you message to foundation@wismed.org.
Thank you message to your white coat sponsor:
Please upload a selfie of you in your White Coat that we may send to the physician who sponsored your coat.

Cancel of
Social Media Photo Release:

I authorize and grant Wisconsin Medical Society Foundation to use my photo and excerpts of my thank you on Facebook, Twitter, Instagram or other social or print media platforms.
Please select:

I grant the Foundation use of my photo and quote in social and print media. I grant the Foundation use of my photo, but not my quote in social and print media. I grant the Foundation use of my quote, but not my photo in social and print media. My photo and quote can only be sent to the donor of my White Coat and may not be used in other Foundation social or print media.
Scholarships and Fellowships

Some of the funds maintained by the Wisconsin Medical Society Foundation are reserved for specific populations. By answering the following demographic questions, we can make sure you receive information about applying for awards you may qualify for. Please note: the Foundation maintains many funds. Even if none of the fields below apply to you, you may still be eligible for funding from the Foundation.
If you are from Wisconsin, which Wisconsin county did you graduate high school from?
Please select all that apply:

I am a member of a recognized Native American tribe. I am a US veteran. I am the first in my family to attend college. I am Black. I am a member of an under-represented minority population other than Native American or Black.
Should be Empty:

Student Membership

White Coat Thank You

Scholarships and Fellowships