Membership Application - International Association of Worksite Health Promotion

IAWHP Membership Application

Membership Dues

Membership Type *

Contact Information Contact Information

Email *

Confirm email address *

Salutation (E.g.- Mr., Ms., Dr.)

First Name *

Middle

Last Name *

Suffix (E.g.- Jr., III, MD, PhD)

Title

Nickname

Company

Address 1 *

Address 2

Address 3

City *

State/Province (Leave as [Select a State] if Not Applicable)

Zip Code *

Country

Website

Phone Number *

Fax Number

Alternate Email

Include me in Membership Directories *
Yes No

Include me in Broadcast Email *
Yes No

Username/Password Username/Password

Please enter the Username/Password you would like to use to login to this website.

Your Username must be unique and must be at least 6 characters.
Passwords must be a minimum of 8 alpha-numeric characters with at least 1 number or 1 letter.

Username *

Password *

Confirm Password *

Additional Information Additional Information

Please select your gender.

What is your birthdate(Please use mm/dd/yyyy)?

What is your race/ethnicity? (optional)

Are you an ACSM Member?

What is your highest degree earned?

What professional certifications do you have? (To select more than one use CTRL and Click)

How many years have you worked in the field?

What is your current work setting?

Please indicate if you employer is:

If you work in a corporate setting- How many sites do you serve?

What is your interest in organization involvement? (To select more than one use CTRL and Click)

* I have read the IAWHP Code of Ethics and agree to abide by it. *

If applying as a student member- I attest that I am currently enrolled at least half-time as a student.

Payment Details Payment Details

Membership Coupon Code

Amount to Charge :

Payment Method:

Enter the name on the bank account according to the information shown on your bank statement. The account number and routing number can be copied from the lower left corner of the check.

Bank Name:
Bank Account Holder Name:
Routing Number:
Account Number:
Account Type:

Name on Card:

Card #:

Expires:

Enable Automatic Renewals?

Select "Yes" in order to be enrolled in automatic membership renewal. The above payment method will become your saved payment method, overwriting anything that may have been previously saved and will be used for future renewals. You can change the automatic renewal setting or saved payment method at any time in either the "Payment Method" or "Membership Auto-Renewal" tabs where you edit your profile.

No Yes