HPHR Supplement Application Form
APPLICANT INFORMATION
Contact Email
*
example@example.com
Submitting Organization
*
Please describe the mission and vision of the organization. Note its intersections with public health and social justice (If not readily apparent).
*
Representative's First and Last Name
*
First Name
Last Name
Representative's Pronouns
*
She/Her/Hers
He/His/HIs
They/Them/Theirs
Zir/Zirs/Zirs
Other
Representative Position/Title
Organization's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Organization's Country
*
Degree
*
SD/ScD
PhD
MD/DO
JD
MA
N/A
Other
LinkedIn URL
*
Proposed Supplement Title
*
Scope and Theme of the Supplement
*
Tentative list of articles to be submitted: Please list the proposed title and author(s) for each piece.
*
What are your goals for publishing with HPHR?
*
What is your publication deadline?
*
Topic areas being addressed in this supplement (select all that apply):
*
Artistic Expression and Health
Body image
Children/Youth
Chronic Disease
Domestic Violence/Intimate Partner Violence
Environmental Health
Epi/Biostatistics
Global Health
Health Care Policy
Health Commnications and Technolgoy
Health Innovation
Human Rights
Immigration / Refugee Health
Infectious Diseases / Immunology
Maternal and Child Health
Mental Health
Mindfulness / Sleep / Rest
Non-infectious Disease
Nutrition
Obesity / Overweight
Occupational Health
Physical Activity
Policing / Surveillance
Quantitative Methods
Qualitative Methods
Racial / Ethnic Minority Health
Sexual / Gender Minorities / LGBTQIA+
Social Determinants of Health / Population Health
Substance Use
Terrorism
Violence (inc. Gun Giolence)
Women / Girl's Health
Other
My institution will be paying via:
Credit Card
Purchase Order
My Products
prev
next
( X )
Supplement (5 manuscripts): Installments
Supplements featuring up to 5 manuscripts. First installment (Total: 4 x $3,750 = $15,000)
$
3,750.00
Supplement (5 manuscripts): Pay in Full
Supplements featuring up to 5 manuscripts. Payment in Full.
$
15,000.00
Supplement (6-11 manuscripts): Installments
Supplements featuring 6-11 manuscripts. First installment payment (Total: 4 x $5,000 = $20,000)
$
5,000.00
Supplement (6-10 Manuscripts): Pay in Full
For supplements featuring 6-10 manuscripts.
$
20,000.00
Quantity
1
2
3
4
5
6
7
8
9
10
Supplement (12-15 manuscripts): Installments
Supplements featuring 12-15 manuscripts. First installment payment (Total: 4 x $6,250 = $20,000)
$
6,250.00
Supplement (12-15 Manuscripts): Pay in Full
For manuscripts featuring 11-15 manuscripts.
$
25,000.00
Quantity
1
2
3
4
5
6
7
8
9
10
Signature
*
Date
*
-
Month
-
Day
Year
Date
Please verify that you are human
*
Payment Methods
Debit or Credit Card
Please click one of the PayPal options to complete payment and
submit
the form.
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