IMA Medical Student Membership Application

IMA Medical Student Membership Application

Thank you for your interest in membership with the Idaho Medical Association and your local County Medical Society. Please complete the application below with your program information and your contact information. This information will be used to process your membership, maintain accurate records, communicate important updates and opportunities, and provide access to member services and events. All information submitted will be handled in accordance with applicable privacy and confidentiality practices.
Full Name

First NameLast Name
Degree you are seeking
Date of Birth

MonthDayYear
Date
Gender
Medical School Information
Medical School Name
Medical School Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Medical School Email Address
example@example.com
Medical School Phone
Please enter a valid phone number.Format: (000) 000-0000.
Program Coordinator Name
Program Coordinator Email
example@example.com
Personal Contact Information
You consent to receive IMA and County Medical Society communications electronically. However, if you do not consent and would like to opt out, please email membership@idmed.org. An email address is required to access IMA online services, including dues payments, profile updates, and event or workshop registrations. Some county medical societies also require an email address for member services and communications. We request personal contact information to keep you informed about events and opportunities that may interest you, particularly as office-managed mailings may not always reach you directly. Information provided in the “Personal Contact Information” section will not be shared with outside individuals or organizations. However, under limited circumstances, certain event sponsors may receive attendee registration information for appropriate event-related follow-up.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Cell phone
Please enter a valid phone number.Format: (000) 000-0000.
Personal Email
example@example.com
Education and Professional Practice Information
Medical School
Graduation Year
Medical Specialty Interest
Profile Photo

Cancelof
IMA Membership Qualification
Date

MonthDayYear
Date
Signature
Which email do you prefer IMA and your County Medical Society sends communications to (including newsletters and event info)?
Should be Empty:

IMA Medical Student Membership Application

Medical School Information

Personal Contact Information

Education and Professional Practice Information