MHA | Michigan Health & Hospital Association

Phone

This field is for validation purposes and should be left unchanged.

To apply for MHA Academic Membership, please complete all questions

Organization Information

Organization Name

Organization Address

Street Address City State Zip

Website Address

Phone

Organization Type

If your organization is applying for membership as a specific college, school or academic unit within a university, please provide the specific name under the other option.

University

Community College

Technical/Vocational

Liberal Arts College

Specialty College

Other

Primary Contact

Name(Required)

First Last

Title(Required)

Email Address(Required)

Phone

Address(Required)

Street Address City State Zip

1st Additional Contact

Name

First Last

Title

Email Address

Phone

Address

Street Address City State Zip

2nd Additional Contact

Name

First Last

Title

Email Address

Phone

Address

Street Address City State Zip

3rd Additional Contact

Name

First Last

Title

Email Address

Phone

Address

Street Address City State Zip

Executive Assistant Contact

Executive Assistant Name(Required)

First Last

Title

Email Address(Required)

Phone(Required)

Address(Required)

Street Address City State Zip

Purpose for Joining MHA

What healthcare-related degrees, certificates and short-term credentials do you offer?

What new or planned programs address current or emerging healthcare workforce needs?

Member Hospital Endorser

Hospital

CEO/Senior Level Executive

Date

To be signed by Primary Contact:
I certify on behalf of my organization that I have read the bylaws of the MHA and agree to support the purpose and objectives of the MHA. I understand that this application, upon being filed, will be referred to the MHA Executive Committee for consideration. I also understand that before becoming a member, we must remit the dues as specified. Electronic Signature:

Full Name

First Last

Title

Signature Date

MHA Academic Membership Application

Organization Information

Primary Contact

1st Additional Contact

2nd Additional Contact

3rd Additional Contact

Executive Assistant Contact

Member Hospital Endorser