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