Patient Navigator Registration Form (GF)

Step 1 of 6

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Contact Information

Name(Required)

First Last

Email(Required)

Phone(Required)

Date of Birth

MM slash DD slash YYYY

Preferred Contact Method(Required)

Address(Required)

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

Demographics

Race / Ethinicity

Gender Identity

Other:

Primary Language Spoken(Required)

Other:

Type of Area You Reside In(Required)

Veteran Status(Required)

Disability Status

Navigation Experience & Interests

Have you ever helped someone navigate the healthcare system?(Required)

Yes

Prefer not to say

What populations have you worked in?(Required)

What barriers have you helped people overcome?

What are skills you exercise when assisting patients? (dropdown) (Select all that apply)(Required)

Scheduling appointments

Insurance navigation

Care coordination

Transportation support

Resource referrals

Health literacy support

Advocacy during appointments

Appointment preparation

Communication with providers on behalf of patients

Have you ever participated in community advocacy before?(Required)

Yes

What types of activities are you interested in?

Sharing stories

Attending community meetings

Participating in surveys

Joining focus groups

Volunteering

Helping with outreach

Other

If other:

Story Sharing and Visibility

Condition‑Based Navigation Experience (Optional)

If you have experience assisting patients with chronic, rare, or long‑term health conditions and feel comfortable sharing, please tell us anything that helps us understand your perspective as a patient navigator. This is completely optional.

Care‑Navigation Experience (Optional)

Is there anything about your experience helping people navigate the healthcare system, or navigating it for yourself, that you would like us to understand as we support your advocacy work?

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

Yes

Maybe

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

Consent & Acknowledgement

Membership Dues Acknowledgement(Required)

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

I understand and acknowledge

Communication Consent(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 and acknowledge

Information Use Consent(Required)

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

I understand and acknowledge

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ADMIN - MEMBER TYPE

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MEMBERSHIP TIER

Payment

Membership Level

Patient Navigator

Total

Credit Card

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Patient Navigator Registration Form (GF)

Patient Navigator Membership Form

Contact Information

Demographics

Navigation Experience & Interests

Story Sharing and Visibility

Consent & Acknowledgement

Payment