Membership Form
Or print this form below and mail to the address at the bottom
Membership Fees:
_____ Organizational $100.00 (up to five members - please open the linked Word file above for a document with space for up to 4 additional members)
_____ Individual $25.00
_____ Student $15.00
Name
Title
Organization
Address State ZIP
E-mail
Phone FAX
Please make checks payable to Idaho Rural Health Association and send with the above form to:
Idaho Rural Health Association
c/o Idaho State University-Meridian Health Sciences
Institute of Rural Health
1311 East Central Drive
Meridian, ID 83642
