Need assistance with this form? Contact our Membership Department (membership@mwpha.org).

Membership Acceptance Form

LAST NAME:

FIRST NAME:

MIDDLE INITIAL:

DEGREE:

ORGANIZATION:

POSITION/TITLE:

PREFERRED MAILING ADDRESS:

CITY:

STATE:

ZIP CODE:

TELEPHONE:

FAX:

E-MAIL ADDRESS:

APHA MEMBER: 

PRIMARY SECTION: 

MEMBERSHIP CATEGORIES AND DUES:
 

ONE YEAR

TWO YEARS
Regular membership $30 $50
Retired membership $25 $40
Student membership $25 $40
COMMITTEES AND AREAS OF YOUR INTEREST AND EXPERTISE

AS A MEMBER YOU HAVE THE OPPORTUNITY TO WORK ON A NUMBER OF COMMITTEES which may be of interest to you. Please put a check mark to the Committee(s) you may be interested in knowing more about:
Advocacy/Health Disparities
Professional Development  Women, Children and Youth
Annual Conference  Sustainable Environment
Development
Finance
Membership
Nominating

YOUR AREAS OF INTEREST AND EXPERTISE ARE IMPORTANT TO KNOW SO THAT MWPHA CAN MORE EFFECTIVELY RESPOND TO INQUIRIES FOR HELP IN THE PUBLIC HEALTH COMMUNITY and allow you to have the option to participate. Please list specific areas of interest and expertise below.

AREAS OF INTEREST

AREAS OF EXPERTISE
 

 Thank you!

MWPHA | P.O. Box 4843 | Cleveland Park Station | Washington, D.C. 20008 | (202) 466-755