Membership Form

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

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 are eligible to join only 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)
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.