500 Montgomery Street, Suite 400, Alexandria, VA 22314

MEMBERSHIP APPLICATION

Letterhead

Yes, I would like to join CHI in its efforts to provide medical, psychological, emotional, and spiritual support to children with life-threatening conditions, their families, and their health care providers, by becoming an:

_____ Individual/Professional Member 125 USD

10% discount on CHI publications; advance notice on new CHI publications; registration fee discount and advance notification of CHI international conference.

______ Institutional Member 750 USD

Allows all employees of member institution to receive 10% discount on CHI publications and a discount on registration fee for CHI international conference. Institution receives a copy of CHI newsletter.

Contact Person: ____________________________________
Title: _____________________________________________
Organization: ______________________________________
Address: __________________________________________
City: ______________ State: _____ Zip: ________________
Country: _________________ Postal Code: ______________
Home Phone: ______________________________________
Work Phone: _______________________________________
Fax Number: _______________________________________
E-mail Address: _____________________________________

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To pay by credit card:
Directions for use

  • Click on “Program Area”
  • Select MEMBERSHIP; click on appropriate level of membership
  • Complete rest of form

Or mail payment in USD, along with this form to:

Children’s Hospice International – Membership
500 Montgomery Street, Suite 400

Alexandria, VA 22314


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