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2005 Membership Renewal Notice - DOC

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2005 Membership Renewal Notice - DOC Powered By Docstoc
					Virginia Rural Health Association

T h e l e ading voic e for r ural h e alt h in Virg ini a

VRHA Membership Application Membership Categories (select one)

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Organization ($150)

Any organization or corporation wishing to sponsor one individual within their organization as an active member (organization agent), and up to three more individuals with the organization as non-active members. The agent has all the rights and privileges of an individual member. Non-agent members of the organization have all the rights and privilege of individual members except the right to vote or be a member of the Association Board of Directors. Any person interested in rural health or rural health care issues and participating in the activities of the VRHA through its committees, constituency groups and board. Individual members may vote at membership meetings, serve as a member of the Association Board of Directors, and serve on committees. Any person interested in rural health or rural health care issues and participating in the activities of the VRHA through its committees, constituency groups and board. Retired members may vote at membership meetings, serve as a member of the Association Board of Directors, and serve on committees. Any full-time student in a health care profession. Student members have all the rights and privilege of individual members except the right to vote, hold office or be a member of the Association Board of Directors. Any person, corporations or organizations who wish to provide financial support to the Association beyond the established membership fees, but not interested in active participation in the governance of the Association. Friends of the Association may not vote, hold office, or serve as a member of the Board of Directors or a committee. Friends of the Association will receive all Association mailings and communications.

Individual ($50)

Retired ($25)

Student ($10)

Friend

Name: _____________________________________________________________________ Title: ________________________________Organization:____________________________ Mailing Address: _____________________________________________________________ City: _______________________________State: ________________Zip: _______________ Phone:_____________________________ Email Address: __________________________________________________
(Please note: meeting notices, weekly updates, etc. will arrive by e-mail unless you specifically request to receive them in another format. Your contact information will not be distributed outside of the VRHA membership.)
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Organization Members – please list up to three persons to serve as non-agent members.
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Contact Name: ______________________ Title: ____________________________ Email: _____________

3 Contact Name: ______________________ Title: ____________________________ Email: _____________ 4 Contact Name: ______________________ Title: ____________________________ Email: _____________

Constituency Groups - please check one category that best describes your interest in rural health. __Health Care Provider __Health Care Administrator __Business/Health Insurer __ Health Care Consumer __Health Policy __Educator __Community Leader __Full time student/resident __Local Government __Other Constituency Organization - please check one category that best describes your institutional affiliation. __Clinic, Solo Practice __Hospital __Extended/Skilled Care __Network; Health System __Managed Care __Group Practice __Public Health __Mental Health __Aging Services __School/University/Education __Oral Health __ Community Health Center __ Emergency Services __ Free Clinic __ Research __ Rural Health Clinic __ Other ________________________________ Committees – please check the committee(s) on which you would like to serve. __ Conference Planning __ Awards __ By-Laws __ Finance __ Legislative __ Media/Public Relations __ Membership __ Nominating __ Research Please list any skills or special projects you would like to assist with: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________
Please print the name of the person who referred you for membership (if applicable):_______________________

Please print this form and mail along with appropriate dues to: VRHA 2265 Kraft Drive Blacksburg, VA 24060

THANK YOU!

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