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
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please click one of the PayPal options to complete payment and
submit
the form.
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