Student Membership Application Thank you for your interest in becoming an OPHA member for 2020/21. Membership will end March 31, 2021. Please complete all applicable sections of the following form. Membership * Student - $ 45.00 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 Please enter a Username to create an account. If you already have an account please login before completing this form. Username * Check Availability Punctuation is not allowed in a Username with the exception of periods, hyphens and underscores. Password Confirm Password Provide a password for the new account in both fields. Profile Information Title Dr. Mr. Mrs. Miss. Ms. First Name * Last Name * Type the name the academic institution you attended and select. If it's not listed, add it to the Other field below. Other Academic Institution Organization Street Address City Country - select - Canada United States Province - none - 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. eBulletin Monthly Newsletter Opt-out NRC Nutrition News in Brief (Daily 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 - none - Membership Renewal Reminder From My Constituent Society Conference Referral By Colleague School Other (please specify) Recruitment Letter For other, please specify: Would you like to be a peer mentor? Yes No Not Right Now Please let us know how you want to be involved with OPHA Participate as a workgroup memberVolunteer for an eventJoin the Student and New Professionals NetworkReceive mentoring or career coachingAll of the aboveNot Applicable Payment Options Payment Method Credit card I will send payment by cheque 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- 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 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 * - none - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Postal Code *
