ISSWSH Membership Fund Application

Application for Dues Waiver
ISSWSH Membership fund was established to support the ISSWSH mission by promoting equity and increasing inclusion among members at all levels of the organization.

A full or partial waiver for membership dues is available to a member in good standing (or a member who has been in good standing within the past calendar year) whose circumstances temporarily have resulted in a significant financial hardship, (including temporary or permanent disability, catastrophe, or medical illness) or a member who chooses to provide care to underserved/marginalized populations whereby their financial reimbursement limits their ability to participate in academic organizations/activities.
Applicant Demographics
Name:*

First NameLast NameCredentials
Gender:*
Race:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone:*
Please enter a valid phone number.
Email:*
example@example.com
Other
Number of years as an ISSWSH member:*
Number of years in practice/research:*
Do you receive discounted membership dues/registration fees from other professional organizations?*

YesNo
Have you previously received a discount on ISSWSH membership?*

YesNo
Member Statement
Please describe your specific situation and the reasons for your request. Please include how your status fulfills the criteria for the waiver. (Additional information may be requested.) *
Dues waiver requested:*

FullPartial
Amount of discount being requested:
Please allow 30 days for your request to be processed and reviewed.
Applicant Acknowledgements
ISSWSH is committed to supporting members during times of financial challenge; the acknowledgements below help ensure a fair, respectful, and transparent review process for all applicants.

Please read and acknowledge the following statements:
1. Accuracy of Information
  I certify that all information provided in this application is true, complete, and accurate to the best of my knowledge.
2. Good Standing Requirement
  I understand that eligibility for this waiver requires current good standing with ISSWSH or good standing within the past calendar year.
3. Temporary or Qualifying Circumstances
  I acknowledge that the Membership Fund is intended to assist members experiencing temporary financial hardship or those whose professional circumstances meet the stated criteria of the fund.
4. Supporting Documentation
  I understand that ISSWSH may request additional information or documentation to verify my eligibility.
5. Confidential Review
  I understand that my application and supporting materials will be reviewed confidentially by designated representatives of ISSWSH for the purpose of determining eligibility.
6. Limited Funding Availability
  I acknowledge that Membership Fund resources are limited and that submission of this application does not guarantee approval of a full or partial waiver.
7. Scope of Waiver
  I understand that, if approved, the waiver applies only to membership dues for the specified term and does not automatically extend to future membership periods, meeting registrations, or other fees unless otherwise stated.
8. One-Time or Time-Limited Nature
  I understand that this waiver is intended to be temporary and may require reapplication for future consideration.
9. Change in Circumstances
  I agree to notify ISSWSH if my financial or professional circumstances change significantly during the waiver period.
10. Non-Transferability
  I understand that any approved waiver applies only to me and may not be transferred to another individual.
11. Professional Conduct
  I acknowledge that maintaining professional and ethical conduct consistent with ISSWSH policies is required for continued membership benefits.
12. Processing Time
  I understand that review of my request may take up to 30 days.
My signature in agreement with the above acknowledgements.*
Should be Empty:

Application for Dues Waiver

Applicant Demographics

Other

Member Statement

Applicant Acknowledgements