Group Membership Form

Group Membership Options

Group Membership Options

Tier 1 (5-15 individuals, 10% discount on PHCR and PHPN per member, unlimited free Fellow and Student memberships)
Tier 2 (16-26 individuals, 15% discount on PHCR and PHPN per member, unlimited free Fellow and Student memberships)
Tier 3 (27 or more individuals, 20% discount on PHCR and PHPN per member, unlimited free Fellow and Student memberships)

Point of Contact for Your Group

Name

First

Last

Title

Group Title Phone

Email

Phone

Hospital/ Institute/Facility Name

Clinic / Department Name:

Please provide the following information for staff members participating in the PHA Group Membership.

Press the + link to add another entry.

Name

Email

Title

If you are listing fellows, please submit fellowship start and end dates.

Press the + link to add another entry.

Name

Email

Start/End dates for fellowship:

Please allow 1-2 business days for your membership invoice to be sent via email.

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