2021 NSAH Membership Application

Please complete application form and submit payment for membership.

NSAH Contact: Gloria Rogers, Executive Director rogersglpt@gmail.com

Name Email Address

Address

Street State Zip Code Country

Primary Phone Profession EDU Credentials University Affiliation Department Other Employer Position

Please indicate status:

Review membership levels for more information. Institutional Membership includes membership for faculty and
students.

Payment

3.5 percent fee has been added to registration fee for online registration

Please click on applicable radio button to select payment amount Institutional member $2500 ($2587.50 USD) Associate Organizational member $2500 ($2587.50 USD) Sustaining member $500 ($517.50 USD) Board Member $250 (258.75) Individual member $100 ($103.50 USD) Faculty $100 ($103.50 USD) Healthcare Professional $100 ($103.50 USD) Other $100 ($103.50 USD) Student member $10 ($10.35 USD)