Survey - Resident & Young Professional Registration

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Resident & Young Professional Registration

PHR's National Student Program supports student advocacy by offering resources, training, networks, and opportunities to make a difference. We invite former students who are moving on to residency or jobs to remain involved with PHR and the Student Program. Please complete this form to sign-up as a Resident or Young Professional member of the 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 faculty member, 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 - Employer:

Question - Not Required - Position or Title:

Question - Not Required - Type of Residency or Position:

Question - Not Required - Medical Specialty:

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:

Question - Not Required - What school did you attend?

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

Question - Not Required - School Type:

Question - Not Required - When did you graduate?

Question - Not Required - What degree did you earn?

Question - Not Required - I would like to continue my involvement with PHR. Please send me information about:

	Mentoring a PHR Chapter
	Joining PHR's Asylum Network and learning how to perform exams for asylum seekers needing a medical affidavit
	Continuing to educate my peers about PHR's work through lunchtime talks and Grand Rounds

Don't forget, the easiest, but still incredibly important, way to help as a busy resident or young professional is to simply donate to PHR. Thank you for supporting PHR.

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