Conjoint Membership Application Thank you for your interest in becoming an OPHA member. Please complete all applicable sections of the following form. Membership * Conjoint - $ 155.00 Please renew my membership automatically. Membership will renew automatically. As a charitable, non-profit organization, OPHA relies on the generous support of health enthusiasts like you. Your donation today helps us do more tomorrow. If you'd like to make a donation, please enter that amount here. Thank you for your support. Total Amount Profile Information Title Dr. Mr. Mrs. Miss. Ms. First Name * Last Name * Job Title Organization Please identify the sector that you work in: Sector * - select Sector - Academia Community Health Consultant Government Healthcare Provider Healthcare Non-Government Organization Other Private Industry Public Health Research Consultancy Street Address City Country - select Country - Canada United States Province - select State/Province - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Postal Code Phone Number Email * Your paid membership includes access to our monthly electronic publications and updates. Please indicate how you would like to stay in touch with the OPHA below. Note: We value your privacy, and you can subscribe or unsubscribe from any of these services at any time Please indicate if you would NOT like to receive the following. Biweekly Member Newsletter Opt-out OPHA Information & Event Updates Opt-out Please select the topics that are of interest to you Areas of Interest AlcoholBreast FeedingBuilt EnvironmentChild and YouthChronic Disease PreventionCommunicable DiseasesEnvironmental HealthFood SecurityHealth EquityHealthy AgingInjury PreventionReproductive HealthCannabisSubstance MisuseMental HealthHealth Eating & NutritionPhysical ActivityHealth PromotionTobacco ControlClimate ChangeHealth System TransformationChild HealthOral HealthSocial Determinants of HealthAll of the Above Are you a member of one of the following OPHA Work Groups or Networks Alcohol Prevention Health, Wellness and Chronic Disease Prevention Health Equity Breastfeeding Promotion Network Built Environment Environmental Health Reproductive Health New Professionals Cannabis Task Group How did you hear about OPHA membership - select How did you hear about OPHA membership - Membership Renewal Reminder From My Constituent Society Conference Referral By Colleague School Other (please specify) Recruitment Letter For other, please specify: OPHA Member Networking Directory * Yes No Through OPHA’s new online networking directory, you will be able to find and connect with other members who may share similar backgrounds and areas of interests, unless you opt out. Payment Options Payment Method Credit card I will send payment by check Credit Card Card Type - select - Visa MasterCard Amex Discover Card Number * Security Code * Expiration Date * -month- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec -year- 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 My billing address is the same as above Billing Name and Address Billing First Name * Billing Middle Name Billing Last Name * Street Address * City * Country * - select - Canada United States State/Province * - select State/Province - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Postal Code * Review your contribution Split Payment How would you like to portion your payments? - select - Monthly In lump sum