Membership Signup - Mobile – CHC Alumni

Membership Signup

The Community Health Center Alumni Association (CHCAA) provides support and camaraderie for those touched by community health centers. Membership is free and offers a variety of complimentary programs and events. Plus, it’s a great way to stay connected and engaged with the CHC family.

Create a username*
Lowercase letters only.

First Name*

Last Name*

Email*

Street Address*

Street Address Line 2

City*

ZIP*

State*
Alabama CHC Affiliation*
Please select your current (most recent) affiliation.
Alaska CHC Affiliation*
Please select your current (most recent) affiliation.
Arizona CHC Affiliation*
Please select your current (most recent) affiliation.
Arkansas CHC Affiliation*
Please select your current (most recent) affiliation.
California CHC Affiliation*
Please select your current (most recent) affiliation.
Colorado CHC Affiliation*
Please select your current (most recent) affiliation.
Connecticut CHC Affiliation*
Please select your current (most recent) affiliation.
Delaware CHC Affiliation*
Please select your current (most recent) affiliation.
District of Columbia CHC Affiliation*
Please select your current (most recent) affiliation.
Florida CHC Affiliation*
Please select your current (most recent) affiliation.
Georgia CHC Affiliation*
Please select your current (most recent) affiliation.
Hawaii CHC Affiliation*
Please select your current (most recent) affiliation.
Idaho CHC Affiliation*
Please select your current (most recent) affiliation.
Illinois CHC Affiliation*
Please select your current (most recent) affiliation.
Indiana CHC Affiliation*
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Iowa CHC Affiliation*
Please select your current (most recent) affiliation.
Kansas CHC Affiliation*
Please select your current (most recent) affiliation.
Kentucky CHC Affiliation*
Please select your current (most recent) affiliation.
Louisiana CHC Affiliation*
Please select your current (most recent) affiliation.
Maine CHC Affiliation*
Please select your current (most recent) affiliation.
Maryland CHC Affiliation*
Please select your current (most recent) affiliation.
Massachusetts CHC Affiliation*
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Michigan CHC Affiliation*
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Minnesota CHC Affiliation*
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Mississippi CHC Affiliation*
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Missouri CHC Affiliation*
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Montana CHC Affiliation*
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Nebraska CHC Affiliation*
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Nevada CHC Affiliation*
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New Hampshire CHC Affiliation*
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New Jersey CHC Affiliation*
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New York CHC Affiliation*
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New Mexico CHC Affiliation*
Please select your current (most recent) affiliation.
North Carolina CHC Affiliation*
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North Dakota CHC Affiliation*
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Ohio CHC Affiliation*
Please select your current (most recent) affiliation.
Oklahoma CHC Affiliation*
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Oregon CHC Affiliation*
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South Dakota CHC Affiliation*
Please select your current (most recent) affiliation.
Pennsylvania CHC Affiliation*
Please select your current (most recent) affiliation.
Rhode Island CHC Affiliation*
Please select your current (most recent) affiliation.
South Carolina CHC Affiliation*
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Tennessee CHC Affiliation*
Please select your current (most recent) affiliation.
Texas CHC Affiliation*
Please select your current (most recent) affiliation.
Utah CHC Affiliation*
Please select your current (most recent) affiliation.
Vermont CHC Affiliation*
Please select your current (most recent) affiliation.
Virginia CHC Affiliation*
Please select your current (most recent) affiliation.
Washington CHC Affiliation*
Please select your current (most recent) affiliation.
West Virginia CHC Affiliation*
Please select your current (most recent) affiliation.
Wisconsin CHC Affiliation*
Please select your current (most recent) affiliation.
Wyoming CHC Affiliation*
Please select your current (most recent) affiliation.
CHC Involvement*
Please select ALL CHC category(s) which apply to you currently, or have in the past: (CHC=Community Health Center)
CHC Patient
CHC Provider
Staff
CHC Volunteer/Intern
Elected Official/Govt Employee
CHC Donor
Vendor/Contractor/Supplier
Other Supporter (not listed above)
Please explain:

Organization Name:

What kind of a Provider best describes your involvement?
Enter number of years spent as a Provider
(example: 10)
Enter number of years spent on Staff
(example: 10)
Enter number of years spent as Volunteer/Intern
(example: 10)
What branch of Government?
Select all that apply.
Federal
State
Local
Staff
What type of contributor?
Select all that apply.
Foundation
Corp
Individual
Vendor
Contractor
Other type of supporter
Organization Name:

Please list Other Supporter type:

Past CHC Experience
Please list any past Health Center experience below. If you need more fields, click the “+” icon to the right of the last field.
CHC Name State Involvement # of Years

Please provide a photo for the Member Directory.
Accepted file types: JPG, JPEG or PNG. Max file size of 5MB.
Accepted file types: jpg, png, Max. file size: 5 MB.
Would you like to be added to our email list?*
We do not share, distribute or sell your information.

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Email
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