OB/GYN Club Membership Application

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*** if applying during spring term, dues are only $10 for 1 semester***
This form is for LECOM Bradenton students interested in applying for annual membership in the Ob/Gyn and Reproductive Health Interest Group. All dues paying students will be granted admittance to this student organization should they be in good standing at LECOM. Dues are $20 and should be paid to @farahazzouz.

Please follow our organization on social media to stay up to date on our latest events and opportunities!
Facebook: LECOM Bradenton Ob/Gyn and Women's Health Interest Group (https://www.facebook.com/groups/233772447265273/)
Instagram: @lecomobgyn
GroupMe: https://groupme.com/join_group/67103800/uhPUCDih

First Name *

Last name *

LECOM email *

What year of training are you entering in the 2021 academic year? *

OMS1

OMS2

OMS3

OMS4

Have you paid dues ($20) to @farahazzouz on venmo? *

Yes

Do you have any food restrictions? list restrictions and designate either allergy, or intolerance. *

If you have not paid dues please list your venmo handle and a payment request will be sent

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