Online CHIA Membership Form

Please fill out, print, and mail this page 
together with a check (payable to "CHIA") for your membership dues.         (Please don't send cash in the mail!)
(include a copy of student ID, if requesting student membership) 

CHIA telephone: 916-669-5305 or by email to CHIA. 

If you are renewing your membership, please also use this form!

Send to: 
The California HealthCare Interpreters Association
One Capitol Mall, Suite 320, Sacramento, CA 95814

 In this form, * indicates a required field

1) My occupation is: (please enter all that apply)

Interpreter      Manager    Physician     Nurse
Administrator   Other Health Professional   Trainer or Educator
Health Interpreter Advocate  Health Technologist
Other - Please Specify

2) My Name and Address is:

*
 *

*
 *       *

*
 *   

4) I am    

5) I speak or interpret the following languages:
                      
                    
                    

6)

7 a) Type of Membership Requested: 

7 b) Corporate member name (if requesting $15 membership as part of organization):
 

8) I want to be a Friend of CHIA and make a tax-deductible donation to 
CHIA, a 501 c) 3) organization in California  in the amount of:
$  

9) I am    or: 

10) If you want to assign your own password 
(4 to 8 characters or numbers) 
for the CHIA website (http://www.CHIA.ws), 
please enter it in the following

10) I am interested in participating in the following CHIA activities:
Interpreter Education Workshops     Standards & Certification    
CHIA Newsletter    Chapter Activities CHIA Board
Fundraising    Other - Please specify:

11) Enter any comments you may have in the space provided below:

Thank you for your interest in joining CHIA!  
Please print the completed form and mail in to CHIA 
with your membership dues check. (Please include a copy of your current student ID if you are requesting a student membership) 
in future we would like to make it possible to pay for membership online, but the extra cost for a secure website make this unfeasible at the moment!


If you have any difficulties using this form, please contact: agger@attglobal.net