NOTE TO STATE EMPLOYEES :  Your membership in TPHA is independent of employment with the Tennessee Department of Health. Please provide your personal contact info for use with advocacy and other issues which cannot be sent to your work address.

You may join online or download this PDF and mail to TPHA using the address on the form.

Having problems registering for membership? For Help and Support with applying or renewing for membership online, please visit our Help and Support page here.

  • Most credit card declines are due to a work address being used instead of home address on the billing screen (second screen) or not checking the “I am not a robot” box.
  • Most double charges result from not checking the final checkout total before submitting after editing your membership details. Empty the cart and submit a fresh membership request to adjust the total back.

 

We Accept for online payments.


Date:

Please check one:  New Member Application     Membership Renewal

First Name:   Last Name:

Degree(s):

Occupation*: Organization Name :

Work Address Line 1: Address Line 2:

City: State: Zip:

Work Email Work Phone Fax Number

THPA sponsor for new member (optional)

Name: Office Address

Only complete the portion below (in this box) if there has been a change the past year. 

Note to state employees
Your membership in TPHA is independent of employment by the State Department of Health. the following information will be used as your contact information, including the Newsletter.

Address Line 1: Address Line 2:

City: State: Zip:


Home Phone Home Email

Senate District # House District #

Gender:
 Male     Female      

Hispanic:
  Yes     No

Age:
 20-29     30-39  40-49    50-59  60-69     70+

Race:
 Caucasian     African American  American Indian / Alaska Native   Native Hawaiin / Pacific Islander
 Asian (Chinese, Filipino, Japanese, Korean, Asian Indian or Thai)     Asian Other Other

Work Setting:
 Rural     Urban   Both

Work Location:
 Academia     Community Based Organization  Federal Government   State Government
 City/County Government    Hospital/Health System Private Industry Indian Health / Tribal Government
Other (If so, please list) :

Please check below the section in which you wish to become a member. Joining a section is optional and you can sign up for more than one section.


Dental
Emergency Preparedness (Section dues $5.00 annually)
Environmental (Section dues $20.00 annually)
Epidemiology & Communicable Disease Section
Health Administration
Health Education / Health Promotion
Nursing (Section dues $10.00 annually)
Nutrition (Section dues $5.00 annually)
Pharmacy
Physicians
Public Health Academics
Students
Vision Care

Payment Information

Individual Membership Fee $30.00
Section Dues (see above)
Student Membership $15
Renewal Late Fee (after 3/15) $10

I have reviewed my registration information for accuracy and agree that all is correct.  

On the next screen please make sure billing address and zip code matches what is on file for the card. 

If you are returning from the checkout to change your information, click this link re-start the application, Click Here and remove all items from the cart, then try again if you need to change any demographic information or other information.