HCEA Membership Application Form

This form is for CREDIT CARDS only.
If you are paying by check or money order as a new or renewing “individual” member,
please contact HCEA at membership@hcea-info.org or call 608-441-1054.

Health Care Education Association
2424 American Lane
Madison, WI 53704-3102

Telephone: 608-441-1054 •  Fax: 608-443-2474
E-mail: membership@hcea-info.org

Please read the following before you begin:

  1. This form is for new and renewing Individual memberships only.  If you are interested in joining HCEA as a Student, Patron, or other membership, please contact HCEA at membership@hcea-info.org or call 608-441-1054.
  2. Student memberships are available only to undergraduate students in health services.
  3. Review the HCEA Membership Types.
  4. The searchable online member directory will not display any of your alternate contact information (i.e. alternate address, phone number or email address).
  5. Fields labeled in Red are required in order to process this form.

Renewing Members Only

Member Number:

 

Current Expiration Date:

 

If you are an HCEA member, in order to complete this form your Member Number and Current Expiration Date must appear above.
To display your member information, please login to retrieve your profile information. You will then
be returned to this form and your member number and profile information will be pre-entered below.
* Please Note: If your membership has been expired more than 30 days, your Member Status will be reset to “New Member.”

Membership Information

Membership Type:

Individual  

Member Status:*

New  

Dues Amount:

95.00  

Membership Expires On:

12-31-2017  

Additional Contribution:

  (Enter amount as whole-dollar numbers only. E.g. 1234)

First Name:

Middle Initial:

Last Name:

Degrees/Licenses:

Title:

Company/Institution:

Primary Mailing Address

Address:

Address 2:

City:

State or Province:

Zip Code:

Country:

  (Leave blank if USA)

Alternate Mailing Address

Address:

Address 2:

City:

State or Province:

Zip Code:

Country:

Preferred Billing Address:

Primary  | Alternate  

Preferred Mailing Address:

Primary  | Alternate  

Phone:

Alternate Phone:

Fax:

Email:

Alternate Email:

Years working in education:

Less than 2 years
2-5 years
5-10 years
10-15 years
15-25 years
More than 25 years
 

 

Years working in health care:

Less than 2 years
2-5 years
5-10 years
10-15 years
15-25 years
More than 25 years
 

 

Health Care Roles:

Patient Education
Staff Education
Consumer Education
Public Health
Consumer Health Library
Health Literacy
Other (Describe)

Include in online member directory:

Yes  | No  

 

Include in HCEA rental list:

Yes  | No  

 

May HCEA send you updates, such as conference abstract submission opening and closing dates; Award and Officer nomination, election results; and conference information (hotels, registration, program/schedule updates, etc.)?

 

Yes  | No  

 

 

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