Health Humanities Consortium Membership

Please complete the information below to join the Health Humanities Consortium

• Title

  • Prof.
  • Dr.
  • Mx

• First Name*

• Middle Initial

• Last Name*

• Title*

• Institution/Company*

• Department/Division

• Office Address*

• City*

• State/Province*

• Zip Code*

• Country*

• Business Phone*

• Mobile Phone

• Office Email*

• Are you:*

  • Faculty
  • Graduate Student
  • Staff
  • Other

• Membership Categories*

  • Institutional --$1,000
  • Individual--$100