Survey - Faculty Registration - Physicians for Human Rights

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Faculty Registration

PHR's National Student Program supports student advocacy by offering resources, training, networks, and opportunities to make a difference. We invite faculty members and Student Chapter Advisors to join the Student Program. Please complete this form to sign-up as a faculty member of PHR's National Student Program, or to update your existing registration information.

Signing-up will allow you to receive important email updates about opportunities for advocacy and education. You will also receive PHR's monthly e-newsletters and occasional action alerts about our latest investigations and ongoing work to stop mass atrocities and severe human rights violations.

(If you are a still a student, please update your registration here. If you are a former or graduating student, moving on to residency or work, please update your registration here.)

Contact Information

If you have previously registered, please and your information will automatically be added to the form.


	Title:
*	First Name: Required
	Middle Name:
*	Last Name: Required
	Suffix:
	Professional Suffix:
*	Email: Required
*	Street 1: Required
	Street 2:
*	City: Required
	State / Province:
*	ZIP / Postal Code: Required
*	Country: Required
	Phone Number:
	Gender:
	Date of Birth:	Date of Birth:

Please enter a user name and password for logging in when you return. You can use this password to update your information or receive personalized content.

*	User Name: Required	5 to 60 characters
*	Password: Required	5 to 20 characters
*	Repeat Password: Required

Question - Not Required - Health Professional Type:

Question - Not Required - Medical Specialty:

Question - Not Required - Area of Teaching

Question - Not Required - What school are you on the faculty of?

Question - Not Required - If your school is not listed above, please enter your school name here.

Question - Not Required - School Type:

Question - Not Required - Are you a PHR Student Chapter Advisor?

Question - Not Required - Employer (may be the same as, or in addition to, the above school):

Question - Not Required - Position or Title:

Question - Not Required - Work Address Line 1:

Question - Not Required - Work Address Line 2:

Question - Not Required - Work City:

Question - Not Required - Work State/Province:

Question - Not Required - Work ZIP / Postal Code:

Question - Not Required - Work Country:

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