Health Humanities Consortium Membership

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Please complete the information below to join the Health Humanities Consortium

Title

Prof.

Dr.

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

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