Student Registration Form Please enable JavaScript in your browser to complete this form.Student Name (as you prefer it on you badge) *FirstLastMedical School Campus Attending *Student AAFP Member? *YesNoGet Acquainted Party (number attending) Selected Value: 0 Contact InformationName *FirstLastAddress *Address Line 1Address Line 2CityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *What is the best way to reach you? *PhoneEmailWhat is your birthplace? *Where did you grow up? *High School Name, City, and State *Is your hometown primarily: *UrbanRuralWhat is your campus? *What is your current medical school year? *Do you have any formal commitment to practice in rural Alabama? *YesNoDate expected to enter residency *Rate your level of interest in the following:Family Medicine *Very MuchSomewhatNot at AllInternal Medicine *Very MuchSomewhatNot at AllOB/Gyn *Very MuchSomewhatNot at AllPediatrics *Very MuchSomewhatNot at AllWhat other factors are important in your decision?Student Name (this counts as your signature): *FirstLastFMIG Sponsor Name *FirstLastDate *Submit