Washington State Public Health Association
4617 - 144th Place S.E.   Everett, WA   98296-6916

Membership Application

 Date: (mm/dd/yy)  

  

   Renewing Membership  Member No.:
  (for renewing WSPHA membership only)
Mr. Mrs. Ms. Dr.
  New Member
First Name  MI Last Name Nickname 
 Job Title: Degree(s):
School Attending (for student memberships) Student I.D. Number Graduation Date (M/Y)

Regular Member ($50)  
Student Member (No charge, copy of ID required)

Retired Member ($25)
WSEHA/WSPHA Dual Membership 2007* ($75)


           *This offer is only for 2007 JCH attendees who are registered for the full conference.

Primary Mailing Address
  Alternate Mailing Address
 Agency/Company Name  Agency/Company Name
 Address Address
City                                                             State /Zip    City                                                             State /Zip   

  My Primary Mailing Address is my:        Home Address           Work Address

Work Phone:

Home Phone:

Fax:

 E-mail address for controversial, legislative and advocacy information:
 E-mail address for newsletters, conference, and general information:

 Major Interest Areas: (please select only two areas)
Assessment Health Planning/Policy Dev. Mental Health
Epidemiology Environmental Health HIV/AIDS Prevention
Social Work Oral Health Vision Care
Injury Prevention Health Administration Occupational Health
Maternal/Child Health Medical Care  Health Ed/Health Promotion
Infectious Disease  Other: (Indicate in box)
Nutrition

   Are you an APHA Member?          Would you be interested in a WSPHA board position?

     If you are interested in being on a committee for WSPHA, or lending your expertise 
    in other ways, please select  any of the options listed below:

Awards Committee  Membership Committee
Historical Committee Legislative & Policy Committee
Public Information  Nominations Committee
Special Projects Committee Newsletter Committee 
Constitution & By-Laws Committee Partnerships Committee 
 Program/Education Committee Review Abstracts for the Joint Conference
Moderate a Session at the Joint Conference  Joint Conference on Health Planning Committee
Monitor Sessions at the Joint Conference
Payment for membership will be made by:     Personal Check         Check from my Agency to be mailed
Purchase Order, please invoice            Complimentary Membership through JCH Sponsorship

Credit Card Payment: 

 American Express MasterCard Visa

 Name of Card Holder (for credit card payments):

If paying by check,  money order, or purchase order:  After you have completed the application print a copy before clicking on the submit button below.  Mail the copy with payment to the address above.  Payment will be matched up with the electronic copy received over the site.

If paying by credit card: The link for processing on-line credit card payments is located on the confirmation page which will come up after you click on the submit button below.  Please print this completed application and click on submit.  Please Note: If you are paying for more than one membership by credit card and/or the membership name is different from that of the credit card holder, you may be asked to provide a list of members being paid by the credit card - especially if you go on-line more than once to process multiple payments with the same card.  WSPHA is charged every time a credit card is processed on this site so please check your entry carefully before submitting credit payment information.  If your card is not successfully going through, please do not try again.  You may be charged by WSPHA for repeated processing fees.  Please e-mail kathy@wspha.org if you have any questions.

A copy of the student I.D. card is required with all Student membership applications.  All memberships expire one year from the date received by WSPHA.  Renewal notices are mailed out one month prior to expiration. Memberships are non-transferable.  If at anytime during the year your mailing address should change, please be sure to contact us.