Membership Registration – Student

  • Membership Type - Student

    Student

    You will be able to complete the payment after you have confirmed your e-mail address.

  • Member Info

    If Yes is selected, your info will appear in the Member Locator/Search. Please note, the following information will be available publically: First name, Last name, Email, City, State, Postal Code, Race/Ethnicity, Languages, Licensed in States, Specialty. Students, Affiliates, and Associates will only appear on the Private Members only directory.
  • Contact Info

  • Minimum length of 8 characters.
  • Required phone number format: (###) ###-####
  • Required phone number format: (###) ###-####
  • Please set or type your location on the map that you would like to display in the members directory (i.e. Tokyo, Japan or 123 Smith Street, San Francisco CA, USA)

  • Please set your location on the map that you would like to display in the members directory.
  • Personal Information

  • Upload (.pdf or .docx only)
  • Upload (.pdf or .docx only)
  • Graduate School Information

    Please make sure all fields below are filled with accurate and up to date information. If all fields are not properly filled (the only exception being "Sub-Specialty"), your form will be rejected.

  • (e.g., UCLA, Los Angeles, CA, USA or "N/A" if this does not apply)
  • Current Training Location

  • (indicate your status for the current academic year)
  • (e.g., Loma Linda VA HCS or Please type "N/A" if this does not apply)
  • (e.g., Loma Linda VA HCS or "N/A" if this does not apply)
  • (e.g., Loma Linda VA HCS or "N/A" if this does not apply)
  • (if applicable; e.g., pediatrics, neuro-rehab, general neuro)
    I allow the website to collect and store the data I submit through this form.