MCDES Membership Form

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First Name: *

Last Name: *

Employer:

Preferred mailing and directory address (please list below) *

Work

Home

Address 1: *

Address 2:

City: *

State: *

Zip: *

Preferred Phone Number: *

Email: *

Confirm Email: *

Comments:

Check All That Apply:

I do not want my name listed in the directory.

I do not want my name shared with other organizations.

Affiliations:

Advocate

Chaplain

Clergy

Corrections

Counseling

Education

Funeral Service

Group Work

Hospice

Medicine

Nursing

Psychology

Public Health

Social Work

Student

Survivor

Volunteer

E.M.S.

Other:

Membership Categories: *

Entitles the institution to send up to three individuals to MCDES conferences and workshops at member rates, receive one copy of the newsletter and directory and other mailings

Individual Membership $25.00

Individual Membership (Retiree) $20.00

Individual Membership (students enrolled in degree programs) $20.00

Institutional Supporting Membership $55.00

After you hit "Submit," please scroll down until you see the payment options. If you wish to make an additional donation to MCDES, please select the "Donate" button on the MCDES home page.

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This form was created inside of Sara Reimann.