VAIMH Annual Membership Application
The annual VAIMH Membership fee = $40 per person.

Membership applications/payments submitted in the last quarter of the year (October - December) = membership will be valid through the remainder of that year and end in December of the following year.

Membership applications/payments submitted between January 1 - September 30 = membership ending on December 31 of that same year.
Email *
Group Membership Discount:
For every 10 memberships paid at $40 per member, 2 memberships are free.
First Name *
Last Name *
Professional Title *
Are you a VAIMH Board Member? *
Employer *
Work Address *
Work City *
Work State *
Work Zip Code *
Work Phone # *
Please enter as xxx-xxx-xxxx
Work Email Address *
What is your Primary Program Type *
Required
Home Visiting Program: please let us know which program you are associated with if applicable.
Home Address *
Home City *
Home State *
Home Zip Code *
Home or Mobile Phone # *
Please enter as xxx-xxx-xxxx
Personal Email Address *
Preferred Email for Correspondence *
Required
Are you currently Endorsed? *
Are you currently in the process of Endorsement? *
Would you like information about the Infant Mental Health Endorsement? *
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