MAPA STUDENT ONLINE CONFERENCE/MEMBERSHIP REGISTRATION INFORMATION FORM While only the items in red are required, we ask that you please provide all of the information (where applicable and available). First Name:   Last Name:   Middle Initial:   Suffix:   Mailing Address:   Address (cont.):   City:   State:   Zip:   E-mail address: (if you do not have one - enter None)   Phone:   Gender:   PA Program:   Graduation Year:   Info to Advertisers:   Allow Release Withhold Info VOLUNTEER FOR COMMITTEES: Student Affairs   Yes No Continuing Medical Education   Yes No Legislative   Yes No Membership   Yes No Public Affairs   Yes No