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Date of Birth

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Phone

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Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Organization / Institution(Required)

Job Title / Role

LinkedIn Profile

Demographics

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If other:(Required)

What type of area do you reside in?(Required)

Are you a U.S. military veteran?(Required)

Includes individuals who have served in any branch of the U.S. Armed Forces, including the National Guard or Reserves, regardless of discharge status.

Yes

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Do you identify as a person with a disability?(Required)

This may include physical, sensory, cognitive, intellectual, developmental, or mental health disabilities, whether visible or invisible.

Yes

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Professional Background & Interests

What best describes your professional background? (Select all that apply)(Required)

Researcher

Policy advocate / policy analyst

Fellow (policy, public health, equity, research, etc.)

Non-clinical academic faculty

Public health professional (non-clinical)

Program manager / coordinator

Community engagement professional

Administrator

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What types of opportunities are you interested in?(Required)

Policy briefings

Research collaborations

Speaking opportunities

Advisory roles

Community engagement

Mentorship

Volunteering

Networking

Other

If other:(Required)

Which areas of health disparities or health equity does your work or interest focus on?(Required)

Social determinants of health

Rural health

Community engagement

Health literacy

Health systems improvement

Workforce development

Equity research

Other

If other:(Required)

Please share a brief description of your work, experience, or interest in health disparities or health equity.(Required)

Do you have interest in joining a NAEHD research committee?(Required)

Yes

If yes, which research committee are you interested in joining?

Story Sharing & Visibility

Would you like to be contacted about opportunities to share your story publicly?(Required)

Yes

If you’re open to sharing, what types of storytelling opportunities interest you?

Social media features

Community events

Advocacy campaigns

Written stories

Video interviews

Other

If other:(Required)

Consent & Acknowledgement

Membership Dues Acknowledgement(Required)

I understand that the Associate membership dues become non-refundable after 48 hours. Any intent to cancel must be submitted within 48 hours of registration to membership@naehd.org

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Communication & Information Use — Consent to Receive(Required)

I consent to receive communications from NAEHD related to my membership, including advocacy opportunities, events, newsletters, updates, and curated resources from partner organizations.

I understand

Communication & Information Use — Data Use Acknowledgment(Required)

My information will only be used to support my participation as an Associate and to provide relevant membership communications. My information will not be shared outside of NAEHD.

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Associate Membership Registration Form (GF)

Associate Membership Form

Contact Information

Demographics

Professional Background & Interests

Story Sharing & Visibility

Consent & Acknowledgement

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