Join NASHIA : Membership Form

Please complete the following information. Payment can be submitted via credit or debit card/Paypal below, mailed to PO Box 1878 Alabaster, AL 35007; or by requesting an invoice below. Questions can be sent to hcushen@nashia.org.

Primary Member Name: *

Job Title: *

Credentials/License(s)/Profession

Agency/Organization: *

Address: *

Address

Street Address Line 2

City State

Zip Code

Phone: *

000-000-0000

Enter Same Email Address in Both Boxes Below: *

Confirmation Email example@example.com

MEMBERSHIP CATEGORIES:

If you have questions, please contact hcushen@nashia.org.

FOR STATE/TERRITORIES GOVERNMENT AGENCIES

AND EMPLOYEES:

STATE AGENCY MEMBERSHIP: $1,000

This membership, for State or Territorial government, includes four (4) representative memberships ($1,200 value) designated by the agency or agencies. Designees can be from various agencies within the State or Territory. Representative memberships can be transferred to others within the State or Territory. States, Washington, DC or Territories may purchase multiple State Agency Memberships.

INDIVIDUAL FULL MEMBERSHIP: $300

This membership is available to any individual employed by a State or Territorial government to include program directors, program staff, emerging leaders, those with interest in head injury and more.

RETIREE MEMBERSHIP: $175

This membership is for individuals who have retired from service with a State or Territorial government and are not currently employed by a Supporting member organization. This unique tier of membership is for those interested in continuing their legacy in the field of head injury and mentoring emerging leaders in State or Territorial governments.

FOR SUPPORTING INDIVIDUALS AND ORGANIZATIONS

(NON-STATE AGENCIES):

INDIVIDUAL ASSOCIATE MEMBERSHIP: $200

This membership is for individuals employed with a business or organization (except for State or Territorial governments) with an interest in prevention, public policy, treatment, rehabilitation, community-integration and service coordination within the field of head injury including administrators and program staff of national and community-based non-profit organizations, medical and rehabilitation providers, researchers and business owners with state and federal contracts.

SUPPORTING ORGANIZATION MEMBERSHIP

FOR PROFIT: $1,500; NON PROFIT $1,000

This membership is for organizations, non-State agencies, or corporations with an interest in prevention, public policy, treatment, rehabilitation, community-integration and service coordination with the field of head injury. Each organization membership includes three (3) Individual Associate Memberships as well as marketing exposures on the NASHIA website, an annual feature in a NASHIA newsletter, and the first opportunity to be a sponsor at the annual conference. Those organizations interested may be non-profit head injury organizations, rehabilitation hospitals, residential service providers, therapeutic service providers, universities and supply companies (assistive technology, durable medical equipment, etc.).

STUDENT MEMBERSHIP: $50

This membership is for individuals who are currently enrolled in a high school or post-secondary institution (transcript verification required). Students with an interest in head injury will benefit from networking with leaders in the field and learning more about becoming a future leader.

BENEFACTOR MEMBERSHIP: $2,000

This membership is for a person or organization/business/association with interest in prevention, public policy, treatment, rehabilitation, community-integration and service-coordination within the field of head injury that recognizes the value of NASHIA’s efforts and contributes $2,000 or more. Benefactor’s generosity will strengthen NASHIA’s mission to assist States in promoting partnerships and building systems to meet the needs of individuals with head injury and their families.

Rev. 9/2019

Please complete the CONTACT INFORMATION BELOW if joining

as a STATE AGENCY MEMBER (4 Representatives)

or as a SUPPORTING ORGANIZATION (3 Representatives).

Primary Contact/Representative 1:

First and Last Name

Job Title:

Agency/Organization:

Address:

Address

Street Address Line 2

City State

Zip Code

Work Phone:

Email:

example@example.com

Representative 2:

First and Last Name

Job Title:

Agency/Organization:

Address:

Address

Street Address Line 2

City State

Zip Code

Work Phone:

Email:

example@example.com

Representative 3:

First and Last Name

Job Title:

Agency/Organization:

Address:

Address

Street Address Line 2

City State

Zip Code

Work Phone:

Email:

example@example.com

Representative 4:

First and Last Name

Job Title:

Agency/Organization:

Address:

Address

Street Address Line 2

City State

Zip Code

Work Phone:

Email:

example@example.com

SELECT ONE PAYMENT METHOD (Indicate Membership Level Below): *

DEBIT OR CREDIT CARD USING PAYPAL PLEASE SEND ME AN INVOICE. CHECK/MONEY ORDER

Donations Welcomed and Tax-Exempt:

I am interested in making a donation. Send me information.

Contact NASHIA’s Member Services Coordinator with any questions: hcushen@nashia.org.