Online Membership Form

Four Issues of The Journal of Health Care for the Poor and Underserved (print and electronic access)
Annual Calendar
Clinician and Community Newsletter (print and electronic access)
Discounts on ACU sponsored events and publications
Clinical Tool Cards, Professional Tool Kits, and Education Modules
Online resources at www.clinicians.org

Membership Categories

Individual ($100) - Benefits described above.
Associate ($60) - Annual income of < $35,000; or members retired from active health practice; includes all benefits described above.
Student ($45) - Print only access to the Journal and other benefits described above.
Student ($35) - Electronic only access to the Journal and other benefits described above.
Clinic ($200) - Three (3) individual memberships (described above) plus 10 additional calendars & recognition within the advocacy calendar, ACU newsletter and website.
Organization ($500) - Four (4) individual memberships (described above) plus 25 additional calendars & recognition within the advocacy calendar, ACU newsletter and website.
Sponsor ($2500) - Four (4) individual memberships (described above) plus 250 additional calendars & recognition within the advocacy calendar, ACU newsletter and website.

If you are currently a member, and are renewing your subscription, enter your membership number below, and click "Find Me."

If you do not know your membership number, enter your email address in this form and have your membership number emailed to you.

If you are not yet a member, simply complete this form, starting with the Member Information.

If your personal information appears below, please update any necessary fields, then continue with the form.

Member Information

Please enter the appropriate information in the boxes below, then click on the Continue button at the bottom of the page.
* All fields with an asterisk (*) are required.

First Name*
Last Name*
Affiliation/Organization
Title/Appointment
Street (or PO Box) Address*
City*
State*	* Non-US subscribers please select dotted line (------------) as state.
Zip/Postal Code*	-
Country
Daytime Phone	I do NOT want my phone number published.
Email Address*
Confirm Email Address*	I do NOT want my e-mail address published.

Membership Categories and Dues Rates*

Sponsor - $2,500
Organization - $500
Clinic - $200
Individual - $100
Associate (income less than $35,000 or members retired from active health practice) - $60
Student - $45 (print subscription)
Student - $35 (electronic subscription)

Postage Rates

Canada/Mexico - $6.60/year
Outside North America - $15.20/year

Membership Info (Membership is catalogued in the following categories.)

Disciplines (Please choose one):
Administrator
Clinical Psychologist
Dentist
Dental Hygienist
Family/Marriage Therapist
Health Educator
Nurse Midwife
Nurse Practitioner
Nurse
Nutritionist/Dietitian
Pharmacist
Physician Assistant
Physician - Allopathic
Physician - Osteopathic
Physical - Therapist
Public Health Nurse
Social Worker
other (please specify)

Specialities:
Adult
Behavioral Health
Complementary/Alternative Medicine
Family Practice
Geriatrics
General Denistry
HIV/AIDS
Internal Medicine
OB-GYN
Pediatrics
Preventive Medicine
Psychiatry
Public Health
Women's Health
other (please specify)

Professional Environment (Which best decribes your primary work environment):
Academic/Teaching
Administration
Clinic Practice
Corporate
In-Training
Non-Profit
Philanthropy
Public Health
Public Policy
Research
other (please specify)

Ethnicity Release: (optional data):

ACU members occasionally request the following demographic data for networking
and mentoring purposes. May we release this information for networking purposes only?

Yes No (If no, your answer shall remain confidential).

Ethnicity : (optional data):
Amer. Indian or Alaska native
Black, not of Hispanic origin
Other Hispanic
Asian or Pacific Islander
Puerto Rican (Hispanic)
White, not of Hispanic origin
Mexican Amer. or Chicano (Hispanic)
other (please specify)

Patient/Client Information(if in clinical setting):
Am. Indian/Eskimo/Aleut.
African American
Asian/Pacific Islander
Hispanic/Latino
White
other (please specify)

Patient/Client Information(if in clinical setting):

Annually, you provide health care services to approximately how many individuals?

Organization Description:
Academic Health Center
Community/Migrant/Homeless Health Center/Clinic
Correctional Institution
IHS/Tribal Health Facility
Federally Qualified Health Center
Free Clinic
Mental Health Clinic
Rural Health Clinic
State or Local Health Department
other (please specify)

Contribution to the Association of Clinicians for the Underserved:

$ .00

Payment Information

Payment Method*
Account Number*
Expiration	Month* Year*

NOTE: If you wish to pay by check, print this form and mail it (with your check) to:

The Johns Hopkins University Press
Journals Publishing Divison
P.O. Box 19966
Baltimore, MD 21211-0966
TEL: (800) 548-1784
FAX: (410) 516-3866

* Check must be made in U.S. dollars and drawn on a U.S. bank.

Billing Information

Billing information should match the information on the payee's credit card.

Check this box ONLY if the credit card bill-to address is the same as address above.

NAME first*	last*
Street (or PO Box) Address*
City*
State*	* Non-US subscribers please select dotted line (------------) as state.
Zip/Postal Code*	-
Country

Additional Comments

Please provide any additional comments below: