TxOHC Membership Renewal Form- 2023

I am renewing as a(n): *

Active Member - $50.00 Annual Fee

Organization Member - $150.00 Annual Fee

Organization Member Name: *

Please complete the following information for your designated representative.

Member ID #

First Name: *

Last Name: *

Credentials:

Employer: *

Title or Position: *

Email Address: *

Phone Number: *

Street Address: *

City *

State *

Zip Code *

*

Please confirm that the information above is current and correct.

Please indicate which organizational group you belong to. If retired, please select the appropriate category based on your previous employment. *

Government (Health Department, Department of Human Services, County, City)

Community (Local community health, community based-clinic, faith-based, business)

Education (School Administrator, School Nurse, PTA, etc.)

Provider (Dentist, Hygienist, Physician, Dental Therapist, etc.)

Public (Foundations, Consumer Advocate, Organizations, nonprofits, etc.)

Policy (State and federal legislature, policy advocate, policy makers, etc.)

Health Plans/Third-Party Payer (Managed care, insurance, health care plans, etc.)

Higher Education/Professional Education (University, medical, dental, hygiene, dental therapy, nursing, allied health)

I am interested in volunteering with the Texas Oral Health Coalition. My interests are in the area(s) of:

If you are interested in participating in your local coalition, please select the Regional Coalition from the list below.

Houston Regional Oral Health Coalition

Austin Regional Oral Health Coalition

North Central Regional Oral Health Coalition (Dallas/Fort Worth/Tyler)

San Antonio Regional Oral Health Coalition

El Paso Regional Oral Health Coalition

Coastal Bend Regional Oral Health Coalition (Corpus Christi)

My area is not represented, I would like to discuss starting a ROHC in the following area. My area is not represented, I would like to discuss starting a ROHC in the following area.

Notes:

Please upload your organization's logo here.