Membership Application

Join the state's premier organization for health care marketing and public relations professionals today. If you are a new member, you will receive a membership packet as soon as your check is received and your membership is processed.

Name*
First Last
Work Email*
Personal Email*

*Due to many firewalls within healthcare IT systems, we kindly ask for a secondary e-mail where we can make sure we can contact you!
Password*
Enter Password Confirm Password
Job Title*
Organization
Phone*
LinkedIn Profile
ex:http://www.linkedin.com/in/exampleuser03
Ext.
Primary Work Address*
Street Address Address Line 2 City State ZIP Code
County*
District (Select One)*
- North
- Southeast
- Southwest
North District Counties: Ashland, Barron, Bayfield, Buffalo, Burnett, Brown, Chippewa, Clark, Door, Douglas, Dunn, Eau Claire, Florence, Forest, Iron, Jackson, Kewaunee, Langlade, Lincoln, Marathon, Marinette, Menominee, Oconto, Oneida, Outagamie, Pepin, Pierce, Polk, Portage,Price, Rusk, Sawyer, St. Croix, Shawano, Taylor, Trempealeau, Vilas, Waupaca, Washburn and Wood

Southeast District Counties: Calumet, Dodge, Fond du Lac, Green Lake, Jefferson, Kenosha, Manitowoc, Milwaukee, Ozaukee, Racine, Rock, Sheboygan, Walworth, Washington, Waukesha, and Winnebago

Southwest District Counties: Adams, Columbia, Crawford, Dane, Grant, Green, Iowa, Juneau, LaCrosse, Lafayette, Marquette, Monroe, Richland, Sauk, Vernon, Waushara
Referred By
If you were referred by an existing member, please mention them here.
Membership Type*
- Regular - ($100) Membership for Healthcare Communicators
- Associate - ($125) Membership for individuals or organizations providing services for healthcare communicators (i.e., agencies, vendors)
- Student - Faculty ($25) Membership for students, Communications faculty or interns pursuing a healthcare communications career
Committee Work Groups: as a member benefit, you can participate on committee work groups in areas that interest you. Check the areas in which you would like further involvement. (optional)
- Communications Review Awards Program - Participate in judging entries that come in for the awards program
- Leadership Recognition Program - Review and score applications received for the recognition program
- Membership Recruitment and Retention - Offer support in recruiting and retaining WHPRMS members.
Payment Method*
To pay by check, please submit this form with payment in the amount correlating to your membership type to:

Liz Kopling
Agrace Hospice & Palliative Care
5395 E. Cheryl Parkway
Madison, WI 53711

Please ensure your name is referenced on the check provided. If names are not included on check payments, this could result in a processing delay with your membership. These instructions will also be emailed to you.
Comments
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