First Name

Last Name

Phone *

Email *

Which city are you interested in? *

Current Career Stage *

How many events per month can you commit to hosting? *

What days/times are you typically available for events? (Events run 7-10pm, setup starts at 6pm) *

Tell us about your professional background *

Which of our signature event themes are you most interested in hosting? (Select all that apply)

Why are you interested in becoming a City Partner with Friends of Medicine? *

What best describes your interest in Friends of Medicine? *

I consent to receive marketing and promotional messages (special offers, discounts, updates) from Friends of Medicine. Message frequency varies. Msg & data rates may apply. Reply STOP to opt out, HELP for help.

I consent to receive text messages about my City Partner application from Friends of Medicine. Message frequency varies. Msg & data rates may apply. Reply STOP to opt out, HELP for help.