Doctoral Membership Registration Form (GF)

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Name(Required)

First Last

Email(Required)

Phone(Required)

Date of Birth

MM slash DD slash YYYY

Preferred Contact Method(Required)

Phone

Mailing Address(Required)

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

Organization / Institution(Required)

Job Title / Role(Required)

LinkedIn Profile

Race / Ethnicity(Required)

Gender Identity(Required)

What is your primary language spoken?(Required)

If other:(Required)

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

Veteran Status(Required)

Yes

Prefer not to say

Disability Status(Required)

Yes

Prefer not to say

Clinical Identity

Clinical Degree(Required)

PharmD

DNP

PsyD

AuD

DDS / DMD

DPT

Other

Other:

Specialty / Subspecialty(Required)

State(s) of Licensure(Required)

Years in Practice(Required)

Primary Practice Setting(Required)

Hospital

Outpatient clinic

Community health center

Private practice

Academic medical center

Long-term care

Telehealth

Other

Health Equity & Disparities Focus

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

Other:

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

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

Policy briefings

Research collaborations

Speaking opportunities

Advisory roles

Community engagement

Mentorship

Volunteering

Networking

Other

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

Yes

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

Barriers & Access

Maternal Health Outcomes

Chronic & Rare Disease

Counseling & Mental Health

Under & Uninsured

Story Sharing & Visibility

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

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 Acknowledgment(Required)

I understand that the 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 & 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 and acknowledge

Communication & Information Use – Data Use Acknowledgment(Required)

My information will only be used to support my participation as a Doctoral Level Clinician member and to provide relevant membership communications. My information will not be shared outside of NAEHD.

I understand and acknowledge

Payment

Membership Level

Doctoral Level Clinician

Total

Credit Card

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Doctoral Membership Registration Form (GF)

Doctoral Level Clinicians Membership Form

Clinical Identity

Health Equity & Disparities Focus

Consent & Acknowledgement

Payment