Membership
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Are you an underrepresented urologist, medical student or future urology applicant interested in Urology Unbound membership (Black or African American, Latino, Native American, Native Hawaiian or Pacific Islander)?*

  • UU Membership Screening

    Membership to Urology Unbound is available for medical students, residents and urologists from backgrounds underrepresented in urology. Please answer the following screening questions.
  • Are you of Hispanic, Latino or Spanish origin?*
  • How would you best describe yourself?*
  • If you identify as Other or Bi-racial/Multi-Racial, do you consider yourself to be of African or Hispanic or Latino or American Indian, or Alaska Native or Native Hawaiian, or Pacific Islander descent?*

  • Research Consent

    DISCLAIMER:  Any personal information that could identify you will be removed or changed before data is either shared with non-Urology Unbound researchers or published. Research consent is REQUIRED for membership.
  • I grant permission for the data collected from this form to be used in the researcher's (Urology Unbound) publications on this topic*

  • Membership Registration

  • Format: (000) 000-0000.
  • Please Select all Degrees Earned*
  • Date of Birth*
     - -
  • Race (Please Select up to 2 Options)*
  • Ethnicity (Please Select up to 2 Options)*
  • Do you identify with any of the following regions?*
  • Gender: How do you identify?*
  • What is your sexual orientation?*
  • Have you been diagnosed with any disability or impairment?*
  • Which of the following have been diagnosed? (Please Select all that Apply)
  • Please select the following descriptors you identify with (Please Select all that Apply)*
  • Did/Does your medical institution have a home urology program?*
  • How did you first hear about Urology Unbound?*
  • Please select your current position*
  • Which of the following best describes your current clinical or professional setting: (select all that apply)*
  • Are you a member of any of these med student organizations (select all that apply)

  • Photo Release

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  • Please select which of the following identifier(s) Urology Unbound may use*
  • Please select the pronouns you prefer:*

  • By signing below, I hereby grant permission to Urology Unbound to use photographs and/or video of me taken on in publications, news releases, online, and in other communications related to the mission of Urology Unbound.

    • I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image. 
    • I allow Urology Unbound to edit, alter, copy, or distribute the photos for social media advertising and marketing.
    • I agree that the photos belong to Urology Unbound.
    • I understand that I will not receive any monetary compensation.
  • Date Signed
     - -
  • Are you a current medical student?*
  • Have you participated in or do you plan to participate in a research year?*
  • Anticipated Med School Graduation Year*
  • What year will you apply for urology residency?*
  • What are your primary goals for participation in Urology Unbound? (Please check all that apply)*
  • What are your primary goals for participation in Urology Unbound? (Please check all that apply)*
  • If applicable, select all of the academic issues you experienced during urology residency/fellowship.*

  • Ways to Support

    Looking for ways to support or volunteer with Urology Unbound? Here's how!
  • There are so many ways to get involved with Urology Unbound! Want to be a volunteer mentor? Partner with us to develop your institution's pipeline program? Collaborate on research? Lets us know below!*

  • Give Back

    At Urology Unbound, we are committed to providing you with valuable resources and enhancing your medical career. While our memberships are offered free of charge, we rely on the generous support of our community to sustain and expand our initiatives.Your contributions enable us to maintain a dedicated team of professionals who manage administrative tasks and cover essential operational expenses, all of which are instrumental in supporting your journey in the field of urology.We genuinely appreciate your willingness to support our cause. If you are in a position to give, we welcome you to consider becoming a donor. Your one-time or monthly donations, regardless of the amount, have a meaningful impact on our mission. Together, we can continue to break boundaries and create more opportunities in the world of urology.Thank you for being part of Urology Unbound, and for any support you can provide to help us reach even greater heights
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