2022 Resident and Fellow Membership Application

First Name
Middle Name
Last Name
Informal Name
Suffix
Title (MD/DO)
Designation (FACS, FAAP, MPH, etc.)
Birthdate ?
Gender
Email (preferred)
Email (alternate)
Cell Phone
Licensure and Training
Grad Year
Medical School:
OH. License Number
Residency/Fellowship Information
Program Name
Program Length Residency/Fellowship Year
Location: City State
Specialty
Subspecialty
Home Information
Home Address
City
State Zip
OSMA Resident/Fellow Membership:
Choose Membership Option:
Check box if interested in Leadership opportunities
I am interested in possibly being profiled and/or providing content for future OSMA communications.
What prompted you to join OSMA?

Take this opportunity to become part of the OSMA Mentorship Program:

Please choose which role you are interested in:
What areas do you hope to share with your mentor/mentee? (check all that apply):
Leadership
Governance, Policy writing
Advocacy
How to network
Navigating work/life prioritization, family, well-being, etc.
How to build a private practice
Scope of Practice
Early career and job advice - contracts, pay structure, etc.
Job settings - private v. academic v. large health, managing hierarchy of academia
Strategies for learning after graduation, honing skills, etc.
Financial - taxes, loans, budgeting, etc.
General
Other
Personal Interests:
Phone (for texts/calls between mentor/mentee)
   - denotes required fields