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

JOIN THE IMCHC ASSOCIATE BOARD

All Associate Board applications are reviewed by IMCHC staff and are subject to approval. For more information on joining, contact Sara Howard at 312.491.8161 x 32 or showard@ilmaternal.org.

 

Please complete and submit for a one-year membership to the IMCHC Associate Board. Dues information is located at the bottom of the page.

 
  SALUTATION
 

FIRST NAME:

 

LAST NAME:

 

ADDRESS:

 

CITY:

 

STATE:

 

ZIP CODE:

 

PHONE:

  Work      Home      Cell

 

EMAIL:

  BEST TIME TO REACH YOU:

 

 

 

Enclosed are dues in the amount of:

 



 

 

 

 
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

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