PRHA Membership Info - 2022
Please fill out the following form for PRHA membership for 2022. A PayPal link will be provided at the conclusion of the form if that is your preferred payment method. If you are paying by check, please complete the form and send the check to:

                                          Pennsylvania Rural Health Association
                                                                 P.O. Box 24
                                                            Patton, PA 16668

If you have any questions, please reach out to paruralhealthassociation@gmail.com

Thank you for your membership!
Sign in to Google to save your progress. Learn more
New or Returning Member? *
How are you paying for your membership? *
Name *
Email *
Phone number *
Mailing Address *
Organization or School *
What type of membership?
Clear selection
If you selected "Organizational" in the previous response, please list up to 5 representatives. Please include name and email addresses for all representatives.
If you selected "other" please specify who you are paying for and what type of membership they should receive: *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Saint Francis University. Report Abuse
Google Forms