Institute for Diversity
Return the completed application and payment to:
Institute for Diversity in Health Management
75 Remittance Drive, Suite 1072
Chicago, IL 60675-1072
OR VIA FACSIMILE TO:
IFD Membership

312-278-0893

INSTITUTE FOR DIVERSITY IN HEALTH MANAGEMENT
APPLICATION FOR ADMISSION TO INSTITUTIONAL MEMBERSHIP

Organizations Eligible for Membership:
All health care-affiliated organizations with an interest in advancing diversity within the field.
Company Info
*Name of Organization
*Main Phone #  xxx-xxx-xxxx
*Street Address
*City
*State
*Country
*Zip Code
Postal Address
Mailing Address
City
State
Country
Zip Code
*Prefix
*First Name
Middle Initial
*Last Name
*Title
*Phone
Fax
*Email Address
*Necessary to Administer Member Benefits. Information will not be published.
CATEGORIES OF MEMBERSHIP:
Our programs and services will help you build a more diverse and inclusive health care workforce and help manage diversity in your organization.
Hospitals And Health Care Organizations Membership:
  Individual Hospitals $500.00
  Multi-hospital System Headquarters (All hospitals must become members) No additional fee for system headquarters. (If all hospitals do not become members, system headquarters is ineligible for membership) $425.00 (per hospital)
  Associate Membership:Other not-for-profit health care organizations
(e.g. health education programs, state associations)
$500.00
  Allied Membership: Health Consultants, Suppliers, Vendors And Other Firms
(Organizations that do not provide direct patient care)
$2,500.00
  Registration Fee: $

How did you learn about Institute Membership?
AHA News Now Bridges Newsletter
Colleague Email
Facebook IFD Blog
IFD Conference Brochure IFD Ebrief
IFD Website Linked in
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Other

PAYMENT METHOD:
CHECK ENCLOSED (Please make check payable to: Institute for Diversity in Health Management)
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CREDIT CARD
The purchaser will be contacted by an Institute staff member via phone or email to complete this transaction.
Purchaser Information
*Prefix:
*First Name:
*Last Name:
Title:
*Street Address:
*City:
*State:
*Country:
*Zip Code:
Phone #:  xxx-xxx-xxxx
Fax #:  xxx-xxx-xxxx
*E-mail:
*Re-enter e-mail address:

***Thank you for requesting to become an Institute member. Please note, upon resignation of a member, any prepaid dues will not be refunded. Thank you.

 

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