NLHN | Membership form

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Membership Form

If you wish to speak with someone prior to filling out this questionnaire, you can send us an email at info@nlhn.net and a member of our staff will contact you within 48 hours.

If you would like to speak with a member of our staff immediately to obtain more information about NLHN and our services or programs, or to receive copies of any of our resources, please call us at 202-965-9633, Mondays through Fridays, 9:00 am through 5:00 pm Eastern Standard Time.

The information in the membership form is treated with utmost care and confidentiality and will solely be used for the purposes of joining NLHN.

*Indicates required fields

*First Name:

*Last Name:

*Title:

*Organization:

*Address:

*City:

*State:

*Zip:

*Telephone:

Fax:

*E-mail:

*Languages Fluent In

*User ID:

*Password:

*Repeat password:

*1. Area of Expertise (Check as many as apply):

	Administrator	Clinician	Family Group
	Focus Group /Marketing	Fundraising	Grant Writing
	Law / Health	Mass Media	Medicine
	Program / Materials Development	Spanish- language adaptations	Program Planning
	Public Relations	Public Speaking	Research
	Service Provider	Program Evaluation	Trainer
Expertise Other:

*2. Opportunities for Collaboration
Please list areas of collaborative activities and/or interests. These include, but are not limited to, the following: networks, policy, resources, training, public speaking, events and technical assistance.

*3.Membership Categories and Dues Please put a check mark next to your membership category

	Individual - $100: Any individual regardless of race, gender, national origin, sexual orientation, religion, age, or political affiliation, who is committed to the mission and goals of NLHN, is eligible for individual membership.
	Corporate - $1500: Any corporation committed to the mission and goals of NLHN is eligible for corporate membership.
	Student - $25: Any individual who is attending school full- or part-time and who presents a school identification card or any appropriate documentation.
	Mature Citizen - $25: Any individual who has reached the age of 60-years

	Non-profit Organization: Any non-profit organization that provides its 501(c) (3)documentation, and has:
	A budget of less than $1 million, and supports the goals of NLHN - $125.
	A budget of over $1 million, and supports the goals of NLHN - $500.

	Small Business - $125: A business of less than 25 employees
Payment
	I have enclosed a check or money order, made payable to the National Latina Health Network, for the full dues amount.
	Please bill me later for my dues payment

Please contact.
Jennifer Levy, Program Associate, with questions regarding membership at

202-965-9633.

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