AHHA INSTITUTIONAL MEMBERSHIP APPLICATION

APPLYING INSTITUTION'S NAME:
Healing Center Name:
QUALIFYING CRITERIA:
To qualify as an AHHA Institutional Member your healing center must:
  • provide health care to individuals
  • provide alternative (complementary) therapies either exclusively, or integrated with conventional (allopathic) medicine
  • offer three or more modes of health care/modalities (such as, chiropractic, massage therapy and nutritional consulting or medical, acupuncture and psychotherapy)
  • have three or more health care practitioners on staff, who are fully trained and legally qualified to deliver the care offered
  • be a legally incorporated business entity (either for profit or nonprofit)
  • be located in North America
Modalities Offered:
List each healing modality offered by your healing center:
Healthcare Staff:
List full names of three key staff healthcare practitioners, who treat patients. Indicate which modalities each is trained and legally authorized to deliver:
APPLYING HEALING CENTER'S CONFIDENTIAL CONTACT INFORMATION:
This information is kept confidential, unless authorized elsewhere for inclusion in listing.
Contact Person Name/Title:
Contact Person Phone:
Contact Person Email:
Mail To Street Address:
Mail To City:
Mail To State:
Mail To Zipcode:
Mail To Country:

HEALING CENTER'S AUTHORIZED DATA FOR PUBLIC LISTING:
The following information is authorized to be in the AHHA Institutional Member's listing shared with the general public in print and online.
Healing Center Name:
Street Address:
City:
State:
Zipcode:
Country:

Phone:
Email:
Website:
Healthcare Approach:
Patient Access:
Holistic Philosophy?:
Treatment Therapies:
Descriptive text listing treatment therapies available for patient care at Center (limit about 250 characters)
Focus of Center:
Descriptive text describing important, unique factors of what healing center offers, such as specific disease conditions treated, success rates, staff team approach, insurance coverage (limit about 250 characters)
MEMBERSHIP REQUEST:
Yes, our healing center grants permission for release of the authorized information for the Healing Centers in North America networking list and other public relations opportunities.

Yes, our healing center wants to become an Institutional Member of the American Holistic Health Association and certifies that the information provided above is accurate.

NOTE: If you elect to submit this form using our online option, you will need to fill in the Signature box below. By typing your full name and today's date in this box you are providing the legal equivalent to your signature in response to the above questions.
SIGNATURE: (enter your full name and today's date)


HELP AHHA GO GREEN:
There are two ways that your healing center can help AHHA be more "green" and reduce our paper consumption:

Access some of your Thank You Packet online

Access the AHHA Members Only Newsletter online
Issues of the bi-monthly AHHA newsletter, published to promote networking among members, are posted in the online Members Only section

MESSAGE TO AHHA:
This area is provided to offer you an opportunity to send a special message to AHHA. Perhaps you wish to clarify something in this application. It would be interesting to know how you discovered AHHA.

CONTRIBUTION INFORMATION:
AHHA is a designated 501(C)(3) - Tax ID# 33-041271
Contributions are tax deductible as allowed by law

$ 110

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BASIC AHHA INSTITUTIONAL MEMBERSHIP CONTRIBUTION
 Our healing center supports the vital work of AHHA! The leading nonprofit wellness and healing information resource, valued by many of the foremost healthcare professionals in America.
$110 is my Institutional Membership annual contribution

For foreign (non-USA) addresses - add an additional $10 toward extra postage costs

ADDITIONAL DONATION
 Our healing center understands that nonprofit AHHA remains free and impartial only through donations. In fact, AHHA's work is funded solely by contributions. Therefore, we want to contribute an additional amount to expand the outreach of this valuable organization.

Of the additional donation amounts over and above basic membership contribution, we select...
Platinum Circle = $500 or more
Gold Circle = $250 - $499
Silver Circle = $100 - $249
Bronze Circle = $50 - $99
Extra Gift = $49 or less

With permission of the donor, an extra donation over and above the basic membership contribution amount is acknowledged in the Honored Donors section of our website at ahha.org/donors.asp with the name of the donor. Gold and Platinum Circle level donors can add a hyperlink.
We grant permission to be added to the Honored Donors list

OUR COMBINED SUPPORT TO AHHA
Type in the total amount you are contributing. This is the sum of basic $110 membership contribution, $10 towards foreign postage (if appropriate), and any additional donation.

SUBMITTAL OPTIONS:
(Option 1) To pay by check, money order or credit card by mail...
Click here for form to download form, printout, complete and mail in.

(Option 2) To pay by credit card using online Secure Server...
AHHA accepts Visa, MasterCard and Discover
  • Fill in ONLINE on this screen all information requested above
  • Print out a copy of all of the above for your records and as back up in case of error in information transfer.
  • Click on "Click here to Pay Online" button below
  • You will be transferred to the Authorize.net Secure Server
Once you have transferred to the secure server, you will be asked to...
Enter Credit Card Number and Expiration Date
Under "Customer Billing Information"
Enter Cardholder Name and Billing Address for Card
If you enter your email address, you will receive an immediate email notification of your transaction from the credit card operation.
AHHA will acknowledge your credit card transaction by notifying you of the authorization code.

Online Payment Service