KYACHW Membership Application
Become a member of KYACHW today! Memberships include CHW, Certified CHW, Non-CHW, Student and Retired. For additional membership information, please contact Samantha Bowman, Kentucky Home Place at samantha.bowman@uky.edu
Date
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Month
-
Day
Year
Name
First Name
Last Name
Mailing Address
Street Address
Street Address Line 2
City
State
Zip Code
Address Type
Home
Office
Phone Number
Please enter a valid phone number.
Email
example@example.com
Organization Name
Organization Address (if different from mailing address)
Position Title
Counties you serve?
How did you hear about us?
Permission for KYACHW to interview, photograph and/or videotape me for use in educational and promotional activities without compensation. If box is not checked, permission for the preceding is granted.
I DO NOT Grant Permission
I Grant Permission
Please list names of organization team members who DO NOT grant permission for pictures to be taken. If everyone on your team grants permission, please leave this box blank.
Membership
Membership applying for (check appropriate box)
INDIVIDUAL (COMMUNITY HEALTH WORKER) Currently employed as Community Health Workers. $25 per year
COMMUNITY(NON-COMMUNITY HEALTH WORKER) Community Members that support the KYACHW mission and community health. (Non-CHW) $30 per year
ORGANIZATIONAL (individual organization paid)
ORGANIZATIONAL TIER 1 (UP TO 10 MEMBERS) Organizations that want to bundle their membership and receive a discount. Please identify each members personal information in the box below. $180 per year **Additional members: (21+) $15.00 each
ORGANIZATIONAL TIER 2 (UP TO 20 MEMBERS) $300 per year**Additional members: (21+) $15.00 each
STUDENT Student members must be enrolled in a degree program. Proof of status is required annually $20 per year
RETIRED Member who has retired and no longer receives income from current CHW work related activities. Proof of status is required manually. $15 per year
Tier 1 (10 members) list names and emails below, for tier 2 (20+ members) use the additional boxes below if needed.
Organization Member
First and Last Name
Email Address
Organization Member
First and Last Name
Email Address
Organization Member
First and Last Name
Email Address
Retired and Student Membership: Please provide proof of status
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Committee
KYACHW is an all-volunteer organization where our member's willingness to share skills, knowledge and expertise allow us to advance our mission. KYACHW members are encouraged to take an active role in the organization by joining a committee. Please select which committee(s) you would like to join.
Do you wish to join a committee?
Membership - Review membership dues, organize outreach and improve memberships.
Nominating - Collect nominations for open offices and submit to executive committee for elections.
Professional Development/Training - Responsible for finding and implementing trainings and professional development for CHW's.
Social Media and Outreach - To design, update and maintain KYACHW website and held responsible for outreach.
Conference Planning - Plan and execute annual conference, also responsible for promoting conference.
I do not wish to join a committee at this time
Payment Information
Mail your check or money order to: KYACHW 750 Morton Blvd. Hazard, KY 41701
Mail in Payment option: Please make payment payable to KYACHW
Check/Money Order
Credit/Debit Card
Invoice
PayPal send payment to kyachw@outlook.com
Check box for the type of membership and quantity. The form will take you to the PayPal platform with the option on the bottom of the login screen to also pay by credit/debit. If membership has already been paid by your organization or you chose to be invoiced, skip this payment section to submit form at the bottom of the page.
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Individual Membership
$
25.00
Quantity
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10
Item subtotal:
$
0.00
Community Membership
$
30.00
Quantity
1
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4
5
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7
8
9
10
Item subtotal:
$
0.00
Organizational Tier 1
up to 10 members
$
180.00
Quantity
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2
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4
5
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8
9
10
Item subtotal:
$
0.00
Organizational Tier 2
up to 20 members
$
300.00
Quantity
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5
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9
10
Item subtotal:
$
0.00
Additional Members
additional organizational members $15 each
$
15.00
Quantity
1
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4
5
6
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8
9
10
Item subtotal:
$
0.00
Retired
$
15.00
Quantity
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2
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8
9
10
Item subtotal:
$
0.00
Student
$
20.00
Quantity
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5
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9
10
Item subtotal:
$
0.00
Donation
$
Free
Quantity
1
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3
4
5
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7
8
9
10
Total Membership Dues
Donation to KACHW (Tax Deductible)
Total Enclosed
Notes
Submit
Should be Empty: