Health Ministries Association / HMA MEMBERSHIP FORM

__ New Member                      __ Renewal                       DATE __ / __ / __

Member Types: (circle one)          Individual (1 member) $40.             Congregational (2 members) $80. (Requires two (2) completed forms)

Institutional/Organizational (5 members) $250. (Requires five (5) completed forms)

NAME: First____________________________ Middle Initial________ Last______________________________________

MAILING ADDR: Street____________________________ City____________________ State/Province_______________

Zip/Postal Code___________________Country_____________________________________

TELEPHONE: Home____________________ Work____________________ Fax_____________________

E-MAIL ADDRESS________________________________________

FAITH GROUP __ Christian __ Jewish __ Buddhist __ Muslim __ Hindu __ Other _________________________________

Denomination or Division (if applicable) _______________________________________________________

MEMBERSHIP MODE (select one) __ Parish Nurse __ Lay Health Minister __ Allied Health Professional __ Clergy/ Chaplain

__ Health Educator __ Program Coordinator      Other ______________________________________________

VOLUNTEER TIME WITH ONE OF THE NATIONAL COMMITTEES: __ Chapter Development __ Newsletter

__ Development __ Finance __ Membership __ Practice and Education __ Resources __ Public Relations

__ I do NOT wish to have my Name,Addr,Phone,etc. published in the HMA Membership Directory

(Signature)__________________________________________

Name of Congregation, Institution or Organization__________________________________________________________

Address: Street______________________________City _____________________ State/Province___________________

Zip/Postal Code__________________ Country ____________________

Chapter Name (if applicable) _______________________________

Mail to: P. O. BOX 7187 ATLANTA, GA 30357-0187 (800) 280-9919 (404) 607-9357
FAX: (404) 607-9358 E-MAIL: hmassoc@mindspring.com

 

FOR OFFICIAL USE: Date Joined _______________________ Fees Paid ______________________

Date Received _____________________Membership Number __________________________________

 

Back To Members Page

Contact UsWho We AreEventsFaith Health IssuesSearch Home

 

HMA
P. O. BOX 7187 ATLANTA, GA 30357-0187 (800) 280-9919 (404) 607-9357
FAX: (404) 607-9358 E-MAIL: hmassoc@mindspring.com
© copyright 2001