Student Membership Registration Form (GF)

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Contact Information

Name(Required)

First Last

Email(Required)

Phone(Required)

Contact Preference(Required)

Date of Birth

MM slash DD slash YYYY

Mailing Address(Required)

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

Academic Institution(Required)

Program of Study(Required)

Degree Level(Required)

Expected Graduation Year(Required)

Academic Information

Program of Study(Required)

Other:

Degree Level(Required)

Expected Graduation Year(Required)

Race / Ethnicity(Required)

Gender Identity(Required)

Primary Language Spoken

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

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

Yes

Prefer not to say

Are you a veteran?(Required)

Yes

Prefer not to say

Professional & Advocacy Interests

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

Select all that apply.

Policy briefings

Educational webinars

Mentorship

Networking

Volunteering

Community engagement

Student‑focused events

Other

Other:

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

Other

Please share a brief description of your interest in health disparities or health equity (optional)

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 Tier Acknowledgment(Required)

I understand that Student Membership is free and is available only to individuals currently enrolled in an eligible academic program. If I have questions about my membership or wish to upgrade once my degree is conferred, I may contact membership@naehd.org.

I understand

Communications Acknowledgement(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

Information Use Acknowledgement(Required)

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

I understand

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Membership Type

Individual - Non-HCP

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Membership Tier

Student

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Student Membership Registration Form (GF)

Student Membership Form

Contact Information

Academic Information

Professional & Advocacy Interests

Story Sharing & Visibility

Consent & Acknowledgement