IMCHC Individual Membership Form

" Transforming maternal and child health in the 21st century "

INDIVIDUAL MEMBERSHIP FORM

We are a coalition of organizations, but encourage individuals to take an interest and participate in our events and programs.

Please fill out and return to us for a one-year annual membership. Dues information is located at the bottom of the page.

	NAME:
	ADDRESS:
	CITY:
	STATE:
	ZIP CODE:
	PHONE:
	FAX:
	EMAIL:

Please volunteer for one or more of the following committees:

		Advocacy/Legislative Affairs		Access to Health Care
		Infant and Maternal Mortality Reduction		School Health Centers
		Childhood & Adult Immunization

Please identify which chapter you would like to join:

Chicago

Springfield

Mt. Vernon

	Membership Dues:	$
	*Total:**	$

Membership fee may be waived upon request.

METHOD OF PAYMENTS:

BY MAIL:

Send check payable to IMCHC. Print this page and submit with payment.

Mailing Address: IMCHC 1256 W. Chicago Ave. Chicago, IL 60622.

ONLINE:

To pay for tickets online visit the Illinois Maternal & Child Health Coalition donation page through the GroundSpring website by clicking the image below.

Thank you for your continued support!

ilmaternal@ilmaternal.org

Tel: 312.491.8161

Fax: 312.491.8171

Illinois Maternal & Child Health Coalition

1256 W. Chicago Avenue

Chicago, IL 60622