This page may not work correctly in your current browser, Internet Explorer. We recommend changing to a more modern browser before viewing this page. We recommend Chrome, Firefox, Safari, or Edge. Individual Membership Application Individual membership is currently free. However, we would like to encourage you to make a nominal donation to support the work of the Council. Membership Level: Individual Individual - $20 Individual - Student - $5 Individual - Consumer - Free How did you hear about the Council? Source Word of Mouth Internet Search E-Blast/Council Publication Social Media (Facebook/Twitter/LinkedIn) Newspaper/Magazine Article Television/Radio Webinar Participant Conference I have been familiar with the Council for a while Other Contact Information: Prefix: Bishop Capt. Cdr Chaplain De Deacon Dr. Dr. & Mrs. Edd Editor Father Lcsw M Ma Minister Miss Mr. Mr. & Mrs. Mrs. Ms. Ms./Capt. Officer Pastor Prince Princess Prof. Prof./Dr. Rabbi Dr. Rev Sgt Rev. Rev. Dr. Royal Sheriff Sister Sr. First Name: Last Name: Suffix: Email: Phone: Home Mobile Other Work Address Type: Home Work School Other Primary Address: Address Line 2 City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix Alternate Address Type: Home Work School Other Alternate Address: Address 2 Line 2 City: State/Province: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip Code: - Address 2 Zip Suffix Professional Information: Degrees/Credentials Clinical Discipline Advance Practice Nurse Case Manager Community Health Worker Dental Hygienist Dentist Medical Assistant Peer Support Physician Physician Assistant Psychologist Registered Nurse Social Worker Substance Use Counselor Other Company Name: Title/Position: Demographics (Optional): Languages Arabic Armenian Bengali Cambodian Chamorro Chinese Creole Croatian Czech English Farsi French German Hindi Hmong Italian Korean Loatian Polish Portuguese Romanian Russian Serbian Slovak Spanish Tagalog Ukranian Urdu Vietnamese Yiddish Ethnicity American Indian/Alaska Native Asian Black/African-American Latino More than one race Native Hawaiian or Pacific Islander Non-Hispanic Other Unreported White Hispanic? Yes No Gender: Female Gender-Fluid Genderqueer Male Non-Binary Other Trans Female Trans Male Birth Date: / / Have you or are you currently experiencing homelessness? Yes No Council Publications: Solidarity Solidarity is a digest on homelessness and health care highlighting new resources, learning opportunities, interviews, and collaborations from the NHCHC along with other information of interest to those in the homeless health care field. (Every four weeks) R&R R&R highlights webinars and other key events, as well as registrations, resources, and job openings. (Every four weeks) Council COVID-19 Flash Blast Council COVID-19 Flash Blast is a brief synopsis of key issues specific to the HCH community, policy developments, resources, and reading lists on the topic of COVID-19. (Every two weeks) Mobilizer Mobilizer is a monthly action alert newsletter focused on public policy issues related to homelessness and health care reform. Mobilizer features opportunities for involvement and activism, and provides brief updates on legislation of particular interest to the HCH community. (Monthly) Respite & Recuperative Care News Respite & Recuperative Care News is an e-publication of the Respite Care Providers’ Network highlighting trends, new resources, and learning opportunities of interest to providers, consumers, and advocates of medical respite care. (Quarterly) NCAB Consumer Voice Consumer Voice is a publication of the Council’s National Consumer Advisory Board (NCAB), which gives people with lived experience of homelessness a voice in national issues involving the health care and housing of people without homes. (Quarterly) Healing Hands Healing Hands, a publication of the HCH Clinicians’ Network, melds scientific knowledge with the experience of clinicians working in Health Care for the Homeless and reflects issues of concern to direct service providers and program administrators who serve people experiencing homelessness. (Two times per year) Which publications would you like to receive? Solidarity R & R Council COVID-19 Flash Blast HCH Mobilizer Respite & Recuperative Care News NCAB Consumer Voice Healing Hands When you complete this form you will be an individual member of the NHCHC. Would you be interested in learning about organizational membership? Interested in learning about organizational membership? Yes In addition to being an individual member, you may also choose one or more of the following groups to become further engaged in specific work and initiatives. Individual Membership Group Clinician's Network National Consumer Advisory Board Respite Care Providers Network Neon CRM by Neon One Join the Council Make A Donation Contact Us Our Networks Respite Care Providers' Network National Consumer Advisory Board HCH Clinicians' Network Get Involved Join Our Organization Donate to Our Cause This website is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $1,625,741 with 20 percent financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov. Copyright © 2021 National Health Care for the Homeless Council, Inc. PO Box 60427 | Nashville, TN 37206 | (615) 226-2292 Disclaimers and Payment Policies FollowFollowFollow
