Form

Member Application

Fee is $25 for Spring Semester and includes a shirt

Full Name*

First Name Last Name

Year in School

E-mail*

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell Phone*

- Area Code Phone Number

Birth Date

Month Day Year

Cultural Background (for statistical purposes only)

How did you find out about LMSA Plus?

Area of Interest, please mark all that apply

Medicine Dentistry Public Health Osteopathic Med Nursing Physical Therapy Physician Assistant Medical Research

Shirt Size

Small Medium Large

I understand that all my personal information is to be kept confidential and information is only to be used for LMSA Plus purposes and/or related activities. Applications can also be printed and dropped off at the Health Professions Office at UH 223 or sent via email toLMSAPlus@gmail.com. If you have any questions, please feel free to contact Mayra Cruz or Kenneth Kang via the LMSA email address. Thank you!