The Maine Public Health Association

SAVE THE DATE

January 18, 2012 - Taking Action to Support the Prevention and Public Health Fund in 2012

April 04, 2012 - Quality Counts Conference 2012

April 10, 2012 - My Farmer, My Plate - Cultivating an Understanding of Food Production

BECOME A MEMBER

If you would like to become a member of MPHA, please click here for a PDF copy of MPHA's membership enrollment form or fill out the form below.

2011/2012 Online Membership Form

PLEASE MAKE SURE TO FILL OUT ENTIRE FORM.

ANNUAL MEMBERSHIP CATEGORIES

YOUR INVOLVEMENT


	Individual - $50 • One 2012 individual membership

	Full-time Student - $10 • Qualification for student rate is 12 credit • hours or more School name:

	Retiree - $25

	Partner Organization - $500 • 2 individual 2012 memberships

	Lifetime Membership - $750 • One individual membership for life • Includes all member benefits plus a 20% • discount on all MPHA events

	Advocate Organization - $1,000 • 5 individual 2012 memberships • Your logo on MPHA website

	Alliance Organization - $2,500 • 5 individual 2012 memberships • Your logo on MPHA website • Gold level meeting sponsorship

	Sustaining Organization - $5,000 • 10 individual 2012 memberships • 10 Annual Meeting registrations • Platinum level meeting sponsorship • Your logo on MPHA website

	I would like to further support the work of MPHA: please accept my additional contribution of $ to advance public health in Maine.

Are you interested in becoming actively involved in MPHA?


	E-news contributor on topic of my expertise:

	MPHA Committee Marketing/Membership Tobacco Policy Obesity Policy Broad public health policy Conference planning Awards/nominations

	Represent MPHA on an external Board or Committee

	Help to plan an MPHA regional meeting

	Other:

Do you want to be added to the monthly e-news*?

Please include me in the MPHA e-directory on website.
(Note: this is a membership only, password protected area)

Please inform me of MPHA public policy advocacy initiatives through e-action alerts*:

*Make sure all your communications from The Maine Public Health Association are reaching you.
Add The Maine Public Health Association (mainepublichealth.org) to your trusted e-mail sender list.

First Name	Middle Initial
Last Name
Occupation	Position/Title
Organiztion
	Home Business
Address
City	State Zip Code
E-mail Address	Password
Phone

	Please enter these numbers to complete this request. This has been added to stop spam.

MPHA is an affiliate of the American Public Health Association,
for more information about APHA, go to www.apha.org.

Site Map :: Site by: J.E.G. Design, Inc.