Indiana Public Health Association Membership

Member Contact Information

• *

  Is this an individual or organizational membership?

  • Individual
  • Organizational
• *

  Is this a new or renewal membership?

  • New Membership
  • Renewal Membership
• Prefix: --Choose-- Mr Mrs Miss Ms Dr Prof Rev Fr Sr Rabbi
• * First Name:
• * Last Name:
• * Email Address:
• * Confirm Email Address:
• * Address 1:
• Address 2:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Phone:
• Cell Phone:

• What type of address is this?

  • Home
  • Work
  • Other

• Promo Code

  Enter Code: Apply

• Fee

  Type	Fee
  Individual Membership - Regular	$60.00
  Individual Membership - Student/Retiree	$25.00
  Individual Membership - Student First Year Member	No Charge
  Organizational Membership - Regular	$400.00

Member Profile

• Organization/Company/Employer/Institution
• Job Title
• Website
• *

  Is this person a student?

  • Yes
  • No
• *

  Is this person staff or faculty at a college or university?

  • Yes
  • No
• * Degree (BS/BA, MPH, DrPH, PhD, etc.)
• *

  Does this person work for a local health department or at the Indiana State Department of Health?

  • Yes
  • No
• *

  Is this person on the board of a local health department or at the Indiana State Department of Health?

  • Yes
  • No

• Is this person interested in getting more involved and/or volunteering with IPHA? If so, let us know!

  • Board of Directors
  • Events
  • Funding & Development
  • Membership & Communications
  • Office/Administrative Support
  • Policy & Advocacy
  • Another Way - email us at info@inpha.org to let us know how you will support IPHA

Additional Member Contact Information

• * County of Residence
• County of Employment
• Address 1:
• Address 2:
• City:
• State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• ZIP Code:
• Phone:
• Fax:

• What type of address is this?

  • Home
  • Work
  • Other

Add Other Members

You may add a maximum of 10

Invitation/Referral

• If you joined by invitation or referral, who invited or referred you?