1) Your occupation: (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) Are you a CHIA member? No, I am not yet a CHIA Member Yes, I am a CHIA Member *

3) Your CHIA Chapter (current or planned) Central Valley Chapter Northern Chapter Southern Chapter

3) Name and Address

Name:        *
Address:    *
Address2:
City:           *
State:                 ZIP:  
Phone:            FAX:  

Email:        

4) You are  male    female

5) Languages 1      2   
                     3      4 
                     5      6 

6) You have been an interpreter for less than a year 1 - 2 years 2-3 years 3-5 years 5-10 years more than 10 years not an interpreter

7) Your Username will be assigned to you - it will include your last name and the first letter of your first name.  We can assign you a password, or you can select your own password.  

  Please assign my password Yes, please assign my password No, I would like to create my own password

   If you want to assign your own password of 4 to 8 characters or numbers, please enter it in the following box   

8) Enter your comments in the space provided below:

Thank you for taking the time to fill out this form.  If you have any difficulties using this form, please contact the CHIA office directly:
by phone:  805-682-1215     by fax:      805-682-1276
by email: agger@attglobal.net   or