Thank you for your interest in Whitetulip Health Foundation membership. Please fill out the below form and click ‘Sign Up’ button to continue your application.

Terms:

$40 / Year

First Name:* First Name Required

Last Name:* Last Name Required

Phone:* Phone is Required

Street Adress:* Street Adress is Required

City:* City is Required

State Name:* State Name is Required

Zip/Postal Code:* Zip/Postal Code is Required

Undergraduate Education University:* Undergraduate Education University is Required

Undergraduate Education City:* Undergraduate Education City is Required

Undergraduate Education State:* Undergraduate Education State is Required

Undergraduate Education Country:* Undergraduate Education Country is Required

Medical School Education University:* Medical School Education University is Required

Medical School Education City:* Medical School Education City is Required

Medical School Education State:* Medical School Education State is Required

Medical School Education Country:* Medical School Education Country is Required

Which Post Graduate Year (PGY) you are in now? (PGY 1-7):* Which Post Graduate Year (PGY) you are in now? (PGY 1-7) is Required

Internship PGY 1 (Residency Type, Department, Hospital, Affiliated Medical School, City, State):* Internship PGY 1 (Residency Type, Department, Hospital, Affiliated Medical School, City, State) is Required

Residency (Residency Type, Department, Hospital, Affiliated Medical School, City, State): Residency (Residency Type, Department, Hospital, Affiliated Medical School, City, State) is not valid

Fellowship (Fellowship Type, Department, Hospital, Affiliated Medical School, City, State):* Fellowship (Fellowship Type, Department, Hospital, Affiliated Medical School, City, State) is Required

Fellowship 2 (Fellowship Type, Department, Hospital, Affiliated Medical School, City, State): Fellowship 2 (Fellowship Type, Department, Hospital, Affiliated Medical School, City, State) is not valid

Other Postgraduate Training (Type, Department, Hospital, Affiliated Medical School, City, State): Other Postgraduate Training (Type, Department, Hospital, Affiliated Medical School, City, State) is not valid

Titles and Positions in other countries (Specialty, highest academic rank and administrative duties):* Titles and Positions in other countries (Specialty, highest academic rank and administrative duties) is Required

Academic Interests:* Academic Interests is Required

Would you like to get email notifications about general announcements?:* Would you like to get email notifications about general announcements? is Required

Yes No

Whitetulip Outreach activities you would like to involve in: Whitetulip Outreach activities you would like to involve in is not valid

Whitetulip Family, Marriage, Social Life activities you would like to involve in: Whitetulip Family, Marriage, Social Life activities you would like to involve in is not valid

Family Marriage Social Life Others

Would you like to involve in activities of local Whitetulip Branch you live nearby:* Would you like to involve in activities of local Whitetulip Branch you live nearby is Required

Yes No

1.Whitetulip Member Reference Name:* 1.Whitetulip Member Reference Name is Required

1.Whitetulip Member Reference Email:* 1.Whitetulip Member Reference Email is Required

1.Whitetulip Member Reference Phone:* 1.Whitetulip Member Reference Phone is Required

2.Whitetulip Member Reference Name:* 2.Whitetulip Member Reference Name is Required

2.Whitetulip Member Reference Email:* 2.Whitetulip Member Reference Email is Required

2.Whitetulip Member Reference Phone:* 2.Whitetulip Member Reference Phone is Required

I certify that the information in this application is complete and correct to the best of my knowledge and in the event I am accepted for membership, I will comply with Whitetulip Health Foundation’s rules and policies.*

I hereby agree to abide the terms and conditions as outlined in this Membership Form. Qualifying individual must meet all of the following eligibility requirements: 1-Be a good standing member of a medical profession or; 2-Be a full-time or part-time student in medical professional school and; 3-Interested in and agrees to support the purposes and activities of WHF and; 4-Recommended by the WHF board, executive officers, or two members. Please write your personal email address below to receive notification about your membership status.*

Would you like to receive SMS messages from us?:* Would you like to receive SMS messages from us? is Required

Yes No

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Password Confirmation Doesn't Match

Password Strength Password must be "Medium" or stronger

Have a coupon?

Coupon Code: