Sign Up Sheet: LMSA FPAC Specialty Sections
Please fill out this form to indicate which specialty section you are interested in joining. Also use this form if you would like to update your information. A new specialty directory will be posted every January 15 and August 15.
Name
*
First Name
Last Name
Professional Email
*
example@example.com
Personal Email
*
example@example.com
Personal Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Second Telephone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you interested in joining the Anesthesiology Specialty Section?
Yes
Are you interested in joining the Cell Biology Specialty Section?
Yes
Are you interested in joining the Dermatology Specialty Section?
Yes
Are you interested in joining the Emergency Medicine Specialty Section?
Yes
Are you interested in joining the ENT Specialty Section?
Yes
Are you interested in joining the Family Medicine Specialty Section?
Yes
Are you interested in joining the Internal Medicine Specialty Section?
Yes
Are you interested in joining the Med-Peds Specialty Section?
Yes
Are you interested in joining the Neurology Specialty Section?
Yes
Are you interested in joining the Neurosurgery Specialty Section?
Yes
Are you interested in joining the Ob/Gyn Specialty Section?
Yes
Are you interested in joining the Ophthalmology Specialty Section?
Yes
Are you interested in joining the Orthopedics Specialty Section?
Yes
Are you interested in joining the Pediatrics Specialty Section?
Yes
Are you interested in joining the PM&R Specialty Section?
Yes
Are you interested in joining the Psychiatry Specialty Section?
Yes
Are you interested in joining the Radiology Specialty Section?
Yes
Are you interested in joining the Surgery Specialty Section?
Yes
Are you interested in joining the Urology Specialty Section?
Yes
Are you a member/alumni of LMSA (Latino Medical Student Association)
*
Yes
No
If applicable what is your clinical specialty? (If no clinical specialty, write in N/A)
*
Please right in title (consider academic, professional, leadership and employment titles)
*
Currently what is your professional role?
Pre-Medical Student
Medical Student
Resident
Fellow
Faculty Member
Physician without faculty appointment
Staff member
Other
What Region are you in?
*
Does Not Apply
LMSA Northeast (Connecticut, Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Washington DC, and Vermont)
LMSA West (Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, Oregon, Utah, Washington, and Wyoming)
LMSA Southeast (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, Puerto Rico, South Carolina, and Tennessee, Virginia, and West Virginia)
LMSA Midwest (Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, and South Dakota)
LMSA Southwest (Arkansas, Colorado, Louisiana, New Mexico, Oklahoma, and Texas)
Submit
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