Student Membership

Name:*

First Name Required Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Your Gender:* Your Gender is Required

Iwi:* Iwi is Required

Iwi (other): Iwi (other) is not valid

Mobile Phone Number:* Mobile Phone Number is Required

Home Phone Number: Home Phone Number is not valid

Komiti/Committee Representation: Komiti/Committee Representation is not valid

Medical Interests: Medical Interests is not valid

Māori Organisations: Māori Organisations is not valid

Research Topics: Research Topics is not valid

University:* University is Required

University (Other): University (Other) is not valid

Current Year of Study: Current Year of Study is not valid

First Year of Study: First Year of Study is not valid

Year of Graduation: Year of Graduation is not valid

Username:* Invalid Username

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Password Confirmation Doesn't Match

No val Please fix the errors above

Free for 1 Year

	Student Membership – Payment Free for 1 Year	$0.00
	Total	$0.00

Student Membership – Payment

Free for 1 Year

$0.00

Total

$0.00