CoPAInT General Membership Form

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Thank you for your interest in CoPAInT, the Collaborative of Pediatric American Indian Trainees. Please complete the following form so we can add you to our General Membership mailing list and keep you in the loop regarding upcoming meetings and opportunities. Please let us know if you have any questions. You can email us at copaintmd@gmail.com.

Name *

Preferred Pronouns

Email *

Current Address *

Home Town, State, Country *

Tribal Affiliation (If Applicable)

Stage of Training *

Pre-Med

PA Student

Graduate Student

Medical Student- MS1

Medical Student- MS2

Medical Student- MS3

Medical Student- MS4

Resident- PGY1

Resident- PGY2

Resident- PGY3

Fellow- PGY4

Fellow- PGY5

Fellow- PGY6

Fellow- PGY7

Other:

Current College/Medical School/Residency Program (Name & Location)

Are you currently a member of any of the following organizations? Check all that apply.

American Academy of Pediatrics (AAP)

AAP Section on Pediatric Trainees (SOPT)

ANAMS

AMA

AMSA

Pediatric Interest Group

School/Program-Specific American Indian/Alaska Native Medical Organization

AAIP

What are your personal goals with CoPAInT?

Policy Work

Advocacy Opportunities

Community Health

Mentorship Opportunities

Career Exploration

Research

Community

Other:

Questions? Comments?

Submit

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