National Health Care for the Homeless Council

Because Health Care is a Right, Not a Privilege

HCH Clinicians' Network Membership Application

Caring. Conscience. Compassion.
Do you dream of ending homelessness? We do.
Membership is open to front-line providers or anyone giving hands-on care to homeless people: Nurses, social workers, substance abuse counselors, mental health therapists, dentists, outreach workers, physician assistants, nurse practitioners, case managers, pharmacists, psychologists, and physicians as well as students in these professions. Membership is nontransferable and dues are nonrefundable. Memberships run from annual meeting to annual meeting, and dues paid before December 31 are effective through June of the following year.

TO JOIN OR RENEW

Complete the application below then hit the Submit button to pay by credit card (you will be directed to a secure site to enter your credit card information)
OR
Complete, print and the mail the application with your check payable to the
National Health Care for the Homeless Council, P.O. Box 60427, Nashville, TN 37206-0427
Organizational Members of the National Health Care for the Homeless Council receive 2 complimentary memberships in the HCH Clinicians’ Network each year they renew or join with the Council. Check the Organizational Member list to see if your agency is a member of the Council. Then contact Pat Petty at ppetty@nhchc.org to find out who your Organizational Membership representative is and if you are eligible for a complimentary membership.

PLEASE PROVIDE THE FOLLOWING INFORMATION

* Required Field
First Name *
Last Name *
Title
Organization
Degrees/Credentials
Mailing Address *
City *
State *
Zip *
Telephone *
Fax
Email
Membership Type *	Practicing Clinician - $35 Student - $15
Voluntary Contribution (Tax deductible)	$
Free Subscriptions via E-Mail	Healing Kids - subscribe HCH Research Update - subscribe HCH Mobilizer: An action alert with information on policy issues affecting homelessness and health - subscribe
Please choose two interest areas, your selections will help other members find you in our members-only online directory. You may select topics that you are familiar with and wish to share your expertize or you may select topics that you wish to learn more about:
Primary
Secondary
Final Preferences	I do not want to receive non-Network mail I do not want my address published in the online membership directory Put my work address in the directory but maill all written correspondence to my home address below:
Home address:
Payment Options:	Credit Card

First Name *
Last Name *
Title
Organization
Degrees/Credentials
Mailing Address *
City *
State *
Zip *
Telephone *
Fax
Email
Membership Type *
Voluntary Contribution (Tax deductible)
Free Subscriptions via E-Mail
Primary
Secondary
Final Preferences
Home address:
Payment Options: