New or Renewal Memberships


Become a Member


Organizations or individuals who want to join the Illinois Maternal & Child Health Coalition should complete our membership form below. All membership applications are reviewed by the IMCHC Board of Directors and are subject to approval. For more information on membership, contact Lilah Handler at 312.491.8161 or ilmaternal@ilmaternal.org.

 

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

 

SALUTATION

FIRST NAME:

LAST NAME:

ORGANIZATION/ AGENCY NAME:

TITLE:

ADDRESS:

CITY:

STATE:

ZIP CODE:

PHONE:

FAX:

WEB SITE:

EMAIL:


Please volunteer for one or more of the following committees:

Campaign to Save Our Babies

Chicago Area Immunization Campaign

Illinois Coalition for School Health Centers

Illinois Premature Infant Health Network

Health Care Reform
IMCHC Board Committees:

Fundraising Committee
Program/Policy Committee
Associate Board (for young professionals)

 

Please identify which chapter you would like to join:

  Chicago

 

Lake County
 

Central Illinois

 

Southern Illinois (Mt. Vernon)
 

 

Enclosed are dues in the amount of:

Based on Your Annual budget/ Revenues**

 



* Fees may be waived upon request.
** Organizational members can register up to four individual members from
   their agency/business. Please submit one form per member.