Access List Application
Please complete this form so that we can process your membership request.
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Email *
First and Last Name: *
Today's date:
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Pronouns:
Degree and specialty: *
Affiliation/Institution and Job Title (medical center, practice name, residency program, medical school, health center name, etc): *
City/State: *
For current students and residents: Residency/school program name
For current students and residents: Expected date of completion
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For current residents: specialty
Please describe whether you are currently providing or training to provide the following services:
Medication abortion
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Procedural abortion
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Contraceptive care
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Other sexual and reproductive and pregnancy care
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How did you hear about the Access List and/or who referred you? *
Other references: please provide names of other List members who can vouch for you and are involved in abortion/SRH care in family medicine/primary care. If you do not know other List members, please write ‘N/A’. *
Why do you want to join the Access List (select all that apply)? *
Required
The Access List strives to be a supportive, community-building, anti-racist and anti-hierarchical space. See Community Guidelines & Agreement and please tick the box below to affirm that you have read the Guidelines and agree to abide by them.  *
Required
All List members will be asked to confirm their emails and re-commitment to List community guidelines annually. This will contribute to List security and will serve as a reminder of the importance of the community guidelines. Failure to follow these guidelines may jeopardize membership status.
Thank you for your interest in the Access List. We will notify you shortly on the status of your application.
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This form was created inside of Reproductive Health Access Project.