Please fill out this form so we can get a better understanding of our membership and your needs. Thank you! Name(Required) First Last Birthday(Required) MM slash DD slash YYYY Hospital or Provider Affiliation What interests you most in HMS?Select all that apply. Professional Development Mentorship Networking Events Community Service Other (Describe Below) What would you like to see HMS focus on?Share your story!What's your background in medicine? What inspired you to go into this field?Current Student?(Required) Yes No Retired?(Required) Yes No Phone Number(Required)Email Address(Required) Home Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
