Chicago MOLA

MEMBERSHIP APPLICATION
Thank you for your interest in becoming a member! Please complete the application questions below.

APPLICANT INFORMATION


If you are a student, please indicate specialty(ies) of interest, which will facilitate matching you with attendings in those fields. If you are a non-physician professional, please choose "Not Applicable":


Please choose your top three interests:
















Please select your expected graduation year


What year did you graduate from your highest degree?











MOLA frequently likes to recognize and engage with members through our social media platforms when they participate in activities and events.

Please share any social media handles you wish to use professionally and share with MOLA:

MEMBERSHIP TYPE & DUES



(e.g., MD, DO, MD PhD)







(e.g., PA, RN, APN, Medical Administrator)





*require a minimum volunteer commitment of 5 hr/ 2 events/year.

2020 Latino Health Symposium Más allá de la Salud (Beyond Health) *

JOIN MOLA MEMBERS COMMUNITY

MOLA community is our tool to enhance members growth and development through collaboration and a virtual networking experience If you uncheck this box you can request the registration later writing to [email protected]

MEMBERSHIP PAYMENT

$
$
$
$
Refund policy: Any director, officer, or member of the Association may resign from any office or from the Association by submitting a written notice of resignation to the President or to any Board member. No dues shall be refunded to any resigning member, officer, or dir