REGISTER NOW AND CREATE YOUR LGBT CHAPTER WEBSITE

REGISTER AS THE SITE ADMINISTRATOR AND PRIMARY CONTACT FOR YOUR SCHOOL'S LOCAL LGBT CHAPTER

*Noted Fields are Required

Medical School: *	Select a school. Albany Medical College Albert Einstein COM of Yeshiva University Alpert Medical School of Brown University Arizona COM* AT Still University SOM* in Arizona Baylor COM Boston University SOM Brody SOM at East Carolina University Case Western Reserve University SOM Columbia University College of Physicians & Surgeons Creighton University SOM CUNY The Sophie Davis School of Biomedical Education Dartmouth Medical School David Geffen SOM at UCLA Des Moines University COM* Drexel University COM Duke University SOM East Tennessee State University Quillen COM Eastern Virginia Medical School Edward Via Virginia COM* Emory University SOM Florida State University COM George Washington University SOM & Health Sciences Georgetown University Medical Center SOM Harvard Medical School Howard University COM Indiana University SOM Jefferson Medical College Johns Hopkins SOM Kansas City University of Medicine & Biosciences COM* Keck SOM of University of Southern California Kirksville COM* Lake Erie COM* Lincoln Memorial University-DeBusk COM* Loma Linda University SOM Louisiana State University HSC SOM Shreveport Louisiana State University SOM in New Orleans Loyola University Chicago Stritch SOM Marshall University Joan C Edwards SOM Mayo Medical School McGill FOM McMaster University Michael G DeGroote SOM Medical College of Georgia SOM Medical College of Wisconsin Medical University of South Carolina COM Meharry Medical College SOM Memorial University of Newfoundland FOM Mercer University SOM Michigan State University CHM Michigan State University COM* Midwestern University's Chicago COM* Morehouse SOM Mount Sinai SOM New York COM of New York Institute of Technology* New York Medical College New York University SOM Northeastern Ohio Universities COM and Pharmacy Northwestern University Feinberg SOM Nova Southeastern University COM* Ohio State University COM Ohio University COM* Oklahoma State University Center for Health Sciences COM* Oregon Health & Science University SOM PCOM* - Georgia Campus Penn State COM Philadelphia COM* Pikeville College SOM* Ponce SOM Rocky Vista University COM* Rosalind Franklin University of Medicine & Science Rush Medical College Rush University Medical Center Saint Louis University SOM San Juan Batista SOM Sanford SOM of University of South Dakota Southern Illinois University SOM Stanford SOM Stony Brook University Medical Center SOM SUNY Downstate Medical Center COM SUNY Upstate Medical University COM Temple University SOM Texas A&M Health Science Center COM Texas Tech University Health Sciences Center SOM Touro COM* Touro University COM* Touro University Nevada COM* Tufts University SOM Tulane University SOM UMDNJ New Jersey Medical School UMDNJ Robert Wood Johnson Medical School UMDNJ Robert Wood Johnson Medical School at Camden UMDNJ SOM* Uniformed Services UHS F. Edward Hebert SOM Univ of Miami Miller SOM at FAU Boca Raton Universidad Central del Caribe SOM University at Buffalo SOM & Biomedical Sciences University of Alabama SOM University of Alberta FOM & Dentistry University of Arizona COM University of Arkansas for Medical Sciences COM University of Calgary FOM University of California, Davis SOM University of California, Irvine SOM University of California, San Diego SOM University of California, San Francisco SOM University of Chicago Pritzker SOM University of Cincinnati COM University of Colorado Health Sciences Center SOM University of Connecticut SOM University of Florida COM University of Hawaii at Manoa John A Burns SOM University of Illinois COM @ Chicago University of Illinois COM @ Peoria University of Illinois COM @ Rockford University of Illinois COM @ Urbana-Champaign University of Iowa Carver COM University of Kansas SOM University of Kansas SOM - Wichita University of Kentucky COM University of Louisville Health Sciences Center SOM University of Manitoba FOM University of Maryland SOM University of Massachusetts Medical School University of Miami Miller SOM University of Michigan Medical School University of Minnesota Medical School - Duluth University of Minnesota Medical School (Twin Cities) University of Mississippi Medical Center SOM University of Missouri - Kansas City SOM University of Missouri SOM (Columbia) University of Nebraska Medical Center COM University of Nevada SOM University of New England COM* University of New Mexico SOM University of North Carolina SOM University of North Dakota SOM & Health Sciences University of North Texas Health Science Center Texas COM* University of Oklahoma - Tulsa COM University of Oklahoma School of Community Medicine University of Ottawa FOM University of Pennsylvania SOM University of Pittsburgh SOM University of Puerto Rico SOM University of Rochester Medical Center SOM & Dentistry University of South Alabama COM University of South Carolina SOM University of South Florida COM University of Tennessee Health Science Center COM University of Texas Health Science Center at San Antonio SOM University of Texas Medical Branch SOM University of Texas Medical School at Houston University of Texas Southwestern Medical School University of Toledo COM University of Toronto FOM University of Utah SOM University of Vermont COM University of Virginia SOM University of Washington SOM University of Western Ontario Schulich SOM & Dentistry University of Wisconsin SOM & Public Health Vanderbilt University SOM Virginia Commonwealth University SOM Wake Forest University SOM Washington University in St. Louis SOM Wayne State University SOM Weill Cornell Medical College West Virginia SOM* West Virginia University SOM Western University of Health Sciences COM of the Pacific* Wright State University Boonshoft SOM Yale University SOM
Abbreviated Version of School Name: *	Limited to 14 characters (i.e.: Univ of Pennsylvania - U Penn). This is needed to accommodate a formatting requirement of your website's layout.
Contact Information
First Name: *
Last Name: *
Year in School:	MS1 MS2 MS3 MS4
Title/Position: *
Email: *
Website Administrator Login Information
Create a Password (max. 20 characters): *

SUPPLY INFORMATION ABOUT YOUR SCHOOL TO CREATE YOUR CHAPTER SITE

All LGBTPM chapter websites are based on a template donated by the University of Penn LGBTPM (2004), but the content will be to tailored to your chapter. Simply submit the following (where applicable):

Medical LGBT Organization: *
Organization Website:	Must include http://
Organization Email:
Organization Listserve:
Name of School's Advisor:
Advisor's Email:
Mission Statement: *	Please keep this to a one paragraph maximum.
Premed Applicant Info: 1. lgbt programming for lgbt applicants (hosting, etc.) 2. lgbt contacts (to ask questions) 3. lgbt resources (faculty, admin, online stuff)
Your School's Non-Discrimination Policy:
Events and Activities (Limited to one here, but more can be added once you receive your site administration information) NOTE: To pledge one hour of LGBT programming for the Plus One Initiative Day of Action, please title the event 'Plus One'.
Event:
Date:
Description:
Web Url (if applicable):	Must include http://
Contact:
Email:
LGBT Resources (Limited to one here, but more can be added once you receive your site administration information)
Resource/Title:
Description:
Web Url (if applicable):	Must include http://
Plus One Curriculum (Limited to one here, but more can be added once you receive your site administration information)
Title:
Description:
Web Url (if applicable):	Must include http://
Number of Hours:    (total length of event)	Only include a number in this field - no text.