Membership Application - Idaho Health Care Association

Associate Membership

Membership Dues

Organization Code

If you were given an add-on password to sign up for your organization, enter it now and hit the submit button. If you do not have an add-on password but believe your organization is already in our system, then please contact us. Otherwise, please fill out the application below to create a new record for you and your organization.

Membership Type *

Create an Add-On Password

Please create an Add-On Password that will be used by your members to join your organization. Members of your organization can enter this password in the field at the top of this application to join your organization.

Contact Information Contact Information

Email *

Confirm email address *

Prefix

First Name *

Middle

Last Name *

Suffix

Title

Informal Name

Company *

Address 1 *

Address 2

Address 3

City *

State

Zip Code *

Website

Phone Number *

CCMail

Include me in Membership Directories *
Yes No

Subscribe to our email list?
Include me in Broadcast Email

Additional Information Additional Information

Please select your Business Type: *

Please add a Business Description (up to 400 characters): *

Payment Details Payment Details

2018 Convention Sponsorship Opportunities: Diamond - presenting Sponsor ($5,000+) - SOLD! Thank you Alliance Insurance! Ruby - Keynote Sponsor ($4,000) Sapphire - Contributing Sponsors ($3,000) Emerald-Featured Speaker Sponsors ($2,000) Hospitality & Technology Sponsors ($500)
Add-On Amount : 2018 Convention Sponsorship
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:

PO #:

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

Associate Membership

Membership Dues

Contact Information Contact Information

Additional Information Additional Information

Payment Details Payment Details

Idaho Health Care Association

Improving lives by delivering solutions for quality care.