LMSA Alumni & Resident Engagement Form
Help us stay connected and grow our mentorship network by sharing your involvement and interests.
Basic Information
Full Name
First Name
Last Name
Personal Email Address (no .edu addresses)
*
example@example.com
LMSA Experience During Medical School
Did you attend a National Conference?
Yes
No
Did you attend a Regional Conference?
Yes
No
Which region were you in during medical school?
Midwest
Northeast
Southeast
Southwest
West
Describe your involvement in LMSA (member or chapter/regional/national position)?
Did you participate in LMSA Plus?
Yes
No
Not sure
How useful was LMSA in your professional development?
Not helpful
1
2
3
4
Extremely impactful
5
1 is Not helpful, 5 is Extremely impactful
What was the most impactful aspect of LMSA (200 words max)?
Current Position
Where are you currently training/practicing? (Medical School/Hospital/Institution + City/State)
Role for the next year (beginning June)
Resident
Fellow
Attending Physician
Alumni (Non-clinical)
Other
Where will you be training/practicing beginning June (Hospital/Institution + City/State)
Specialty
Please Select
Anesthesiology
Dermatology
Emergency Medicine
ENT
Family Medicine
Internal Medicine
Med/Peds
Neurology
OB/Gyn
Opthalmology
Orthopedic Surgery
Pediatrics
PM&R
Psychiatry
Radiology
Surgery
Urology
Other
Which region will you be beginning June?
Midwest
Northeast
Southeast
Southwest
West
Mentorship Engagement
If you interested in serving as a mentor for students, please fill out the following form (copy and paste): https://docs.google.com/forms/d/e/1FAIpQLSeWw5qfC3EeIgI7jzturab_g7oPQi36VxhQj95n_PAupzhIyg/viewform
I filled out the form
Not interested
Maybe
Communication Preferences
Would you like to receive the LMSA monthly newsletter and important updates (i.e. National Conference, SALUD Summit, etc)?
Yes
No
Are you open to being contacted for:
Speaking opportunities
Mentorship programs
Events
Leadership opportunities
Scholarship Review Committee
Submit
Should be Empty: