2023 New Membership Form

All information provided in this application is for the use of the DFW-CHW Association. This information will be protected under all HIPPA regulations and other privacy laws allowed. All personal information is to be used only in the distribution of information and announcements provided by the association and its partners.

* Required information

Personal Information

* First Name:
* Last Name:
* Email Address:
* Confirm Email Address:
* Address 1:
* City:
* State:
* ZIP Code:
* Phone:
* Emergency Contact Name
* Emergency Contact Phone Number
* Date Applying
Promo Code

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Fee

Type	Fee
CHW Student	$15.00
Certified CHW/ CHW Instructor	$25.00
2 Year CHW/CHWI Membership - Best Deal!	$40.00
CHW Ally (Non-CHW member)	$30.00

Business Information

Employer Name/Organization
Job Title:

Additional Information

* CHW and/or CHWI #: (if Ally, type 000)
Preferred langauge

Items for sale

Item Qty. Max Limit Price

Item	Qty.	Max Limit	Price
DFW-CHW Association baseball hat This lightweight 100% cotton twill cap features an unstructured crown, pre-curved visor and five-panel construction. It also offers an adjustable self-material strap with a hook-and-loop closure.		200	$15.00 each

DFW-CHW Association baseball hat

This lightweight 100% cotton twill cap features an unstructured crown, pre-curved visor and five-panel construction. It also offers an adjustable self-material strap with a hook-and-loop closure.

200

$15.00 each

Payment

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