Membership Application


CALENDAR Clinical Trials Articles Member Announcements Classifieds Member Benefits Member Tools Member Update Info Form Interested in becoming a member? Membership Info Brochure Membership Application	Membership Application For a printable version for faxing, CLICK HERE PLEASE NOTE: A JCHA MEMBER IS AN INDIVIDUAL NOT A PRACTICE. A JCHA MEMBER IS A HEALTHCARE PROVIDER AND HAS DIRECT CONTACT WITH PATIENTS. If you do not have direct contact with patients, you may be a JCHA Sponsor but not a member. Below are the JCHA Membership options. See the JCHA bylaws for full membership criteria and benefits. Active Primary Members are individuals whose office is physically located in the City of Johns Creek or Technology Park, are healthcare providers and have direct contact with their patients. $200/year Active Primary Members may attend all JCHA functions, vote and may hold a JCHA office. See the JCHA bylaws for full membership criteria and benefits. Active Secondary Members are individuals whose office is physically located in the City of Johns Creek or Technology Park, are healthcare providers and have direct contact with their patients. There must be at least one Active Primary JCHA member from your practice to qualify for this membership level. $100/year Active Secondary Members may attend all JCHA functions and vote but may not hold a JCHA office. See the JCHA bylaws for full membership criteria and benefits. Associate Members are individuals whose office is physically located OUTSIDE the City of Johns Creek or Technology Park, are healthcare providers and have direct contact with their patients. $100/year Associate Members may attend all JCHA functions but may NOT vote or hold a JCHA office. Associate Members will not be a part of the JCHA member database accessible to patients via the JCHA search engine. See the JCHA bylaws for full membership criteria and benefits.
	Member Level

	Full Name (req.)
	Credentials (ie. MD, FACS, PhD, etc.
	Business/Practice Name
	**E-mail (req.)**	This email will be used for JCHA billing, notices and all correspondence - please instruct your email program to accept emails from maryann@theassociationcomany.com
	Website	http:// Please add a link on your site to ours (http://www.johnscreekhealthcare.org) This will improve our ranking on search engines.
		If applying for Primary or Secondary memberships, MUST list Johns Creek office here. Associate membership applicants may list their address here as well.
	Street Address (req.)
	City (req.)
	Zip Code (req.)
	**Office Phone** (req.)
	Cell Phone
	FAX (req.)
		If applying for Primary or Secondary memberships BUT you wish to have correspondence sent to an office other than your Johns Creek office, please list that information here.
	Street Address
	City
	Zip Code
	**Office Phone**
	FAX
	Notes
	Committees	I would be interested in joining the Click here to learn more about each committee.
		Upon submitting this form, your application will be automatically emailed to our Executive Director's office. You will receive an invoice for the Membership Level you've chosen. You may pay that invoice by check or credit card. Paying fees and dues online is not available at this time, but will be in the future! Contact us with questions!