TxOHC Membership Form-2023

I am applying as a(n): *

Associate Member - Complimentary

Student Member - Complimentary

Active Member - $50.00 Annual Fee

Organization Member - $150.00 Annual Fee

Organization Member Name: *

Please complete the following information for your designated representative.

First Name: *

Last Name: *

Credentials:

Employer: *

Title or Position: *

Name of Accredited Institution ( e.g. Univ., Community College): *

School: *

Department/Program: *

Graduation Date: *

Email Address: *

*

Please confirm your email address is correct

Phone Number: *

Street Address: *

City *

State *

Zip Code *

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

GOVERNMENT - State/Local Health Dept, Inter-agency and/or Interdepartmental, Environmental Health, Dept of Education, Dept of Social Services

COMMUNITY - Local Community Health Depts., Community-based Clinics, Community Water Supervisors/managers, Business leaders, Faith-based orgs/Foundations

EDUCATION - Local School Administrator, PTA, School Nurse Association, Dept of Education, Dept of Higher Education Regional Staff

PROVIDERS - Dentists, Dental Hygienists, Physicians, Hospitals and their Respective Associations

PUBLIC - Foundations, Consumer Advocates, Patient Care Advocates, Organizations that promote oral health, Organizations that promote improved quality of life, John Q Public

THIRD-PARTY PAYERS - Managed care, Insurance, Medicaid

POLICY - State and Federal: Legislators, Policy Advocates, Local and Community Policy Makers

HIGHER/ PROFESSIONAL EDUCATION – Universities, Dental and Dental Hygiene Schools, Nursing Schools, Medical Schools and Allied Health Schools

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 community, please select the regional coalition closest to you so the regional coordinator may contact you.

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:

Who should we thank for encouraging you to join TxOHC?

Please upload your organization's logo here.