Healthcare Student Membership Verification

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Phone Number

Please enter a valid phone number.

4

What type of professional program are you enrolled in?* This field is required.

Physician - MD or DO

Pharmacist - PharmD

Physician Assistant - PA

Nurse practitioner - NP

Psychology - PsyD or PhD

Psychology or Social Work - MFT, MSW, MA

Other

5

What other healthcare program are you enrolled in?

6

What is your current status as a student?* This field is required.

Full time

Part time

Leave of absence

Academic suspension

7

What is the expected month and year of your graduation?* This field is required.

8

Please upload a document proving enrollment in a healthcare program. The document must contain your name, name of program or institution, and date of issue (e.g. enrollment verification letter, copy of current/valid study ID, intern or other professional trainee licensure, recent transcript etc.)* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

You may upload multiple files if wanted to necessary

9

By clicking 'agree' below I verify that I'm a student enrolled in a healthcare program and that all information submitted is accurate and truthful. I understand that the healthcare student membership is ineligible for discounted consultation services.* This field is required.

Agree