Az School-Based Membership Application          Print this page



Name:_______________________________________  Date:___________________
Title:________________________   Employer:____________________________________

Mailing Address

Street:__________________________ City:_____________________ State:_____
Zip Code:________________
Contact Phone:(      )________-_____________
Contact Email:_________________________________

Membership Category - please mark your selection

_____Individual-$40.00 yearly (One voting membership)
_____Organization-$400.00 yearly (Includes 3 voting memberships)
 Additonal Member: ___________________________  Email: _______________________
 Additonal Member: ___________________________  Email: _______________________
_____Student-$10.00 yearly (Non voting membership)
_____Donation: Amount: $______________  (Tax Deductible-consult with your tax advisor)
Total:$ _________________
Additional Information/Comments




Make payment/donations to: Arizona School-Based Health Alliance
Mail to:  P.O. Box 40335  Phoenix, Az  85067-0335
(Please do not send cash - Check or Money Order Only Please. Thank you)