Nominee Response
Student Advocate Award
Qualification Requirements
I am an osteopathic medical student
Please Select
Yes
No
I am completing or have completed a portion of my medical education in the Cleveland district (Lorain, Cuyahoga, Geauga, Ashtabula or Lake counties)
Please Select
Yes
No
I am currently a 2nd or 3rd year student in osteopathic medical school
Please Select
Yes
No
Demographic Information
Name
*
First Name
Middle Name
Last Name
Current Medical School Year
*
Please Select
OMS-1 (not eligible)
OMS-2
OMS-3
OMS-4 (not eligible)
OMS-5 (not eligible)
AOA Number
Email
*
example@example.com
Current Mailing Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical School
*
Graduation Year (anticipated)
*
Base hospital / campus
*
Who nominated you for this award?
Please Select
Physician DO
Resident
Peer - fellow student
Self
DME
Asoc. Dean to GME
Admin. Staff
Other
All About You - Tell Us Your Story
Please tell us about yourself. Do not include your name or school name in this field
*
0/250
Why did you choose and what do you love about osteopathic medicine?
*
0/250
Submit
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