Affiliate Sign Up

Organization Details

Please type in your organization's information. A Regular Affiliate account allows for one individual membership under your organization. A Sustaining Affiliate account allows all employees to become individual members and gain the benefits of an IPHA membership.

Organization

Acronym

Street Address

Street Address 2

City

State

Zip Code

County

Website

Type of Affiliation

Number of Employees

Primary Contact Information

Fiscal Contact First Name

Fiscal Contact Last Name

Fiscal Contact Email

Fiscal Contact Phone

Administrator First Name

Administrator Last Name

Administrator Credentials

Job Title/Position

Administrator Email

Administrator Phone

Regular Affiliate Member Information

Signing up a Regular Affiliate account allows for 1 member account. Please fill in the following to set that account up, rather than having to sign up through the member accounts page. Administrator Contact will be used for member details.

Member Password

Prefix

Suffix

Street Address

Street Address 2

City

State

Zip Code

What is your gender identity?

What are your preferred pronouns?

Race/Ethnicity

If you currently a student, please indicate the school you are a student at

Which of the following best describes your place of work/study?

Sections and Special Primary Interest Groups (SPIGs)

IPHA Sections and SPIGs represent major public health disciplines or programs. You can connect with other members to develop scientific program content, write policy papers in your field(s) of practice and network both professionally and socially. IPHA dues include membership in two (2) Sections or SPIGs.

Section/SPIG 1:

Section/SPIG 2:

Donations

Donation Amount

Custom Amount

$10

$25

$50

$100

$150

Custom Amount

Membership Details

Registration fees can be paid via credit card. Payments made by credit card will include a 3.5% processing fee. This fee is charged to cover the processing costs associated with credit card payments.

Invoice Payment Method

Membership Dates

Your membership will be valid from to

Affiliate Total: $0.00

Donation: $0.00

Total: $0.00

After submission you will receive an invoice email from our payment provider. To complete your registration you will need to either pay the invoice online or send us a check. If Credit Card was selected above you will also be shown a link in the success message which you can use to pay immediately if you choose.

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