Membership Application

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.
Mentorship Program - Mentor an entry-level marketing professional in the organization, or request to be mentored by a more senior-level professional in the organization.

Payment Method*

To pay by check, please submit this form with payment in the amount correlating to your membership type to:

Clair McNamara
580 N Washington St.
Janesville, WI 53548

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.

Email

This field is for validation purposes and should be left unchanged.