AHHA PRACTITIONER MEMBERSHIP APPLICATION

APPLICANT'S NAME:
Full Name:
Gender:

APPLICANT'S QUALIFYING CRITERIA:
To qualify for AHHA Practitioner Membership an applicant must have completed formal training for at least one healing modality and have authorization to practice (such as any locally required license or certification), if needed. Note that a certificate of completion is not professional certification. In-progress training does not count until completed. Self study, self-developed programs, organizational memberships, and career positions are not considered formal training. The information provided is kept in the AHHA office computer and is shared with the public, on request. For each modality training, license, and certification mentioned in your listing, the following must be provided:
Modality                  Name/Type Training                  Training Institution or Individual                  Year Completed


APPLICANT'S CONFIDENTIAL CONTACT INFORMATION:
This information is kept confidential, unless authorized elsewhere for inclusion in listing.
Name of Business:
Street Address:
City:
State:
Zipcode:
Country:
Work Phone:
Home Phone:
Cell Phone:
E-mail:
MEMBER'S AUTHORIZED DATA FOR PUBLIC LISTING:
The following information is authorized to be in the AHHA Practitioner Member's listing shared with the general public in print and online.
First Name:
(May include middle name/initial)
Last Name: (searchable field)
Initials after name:
(For educational/professional degrees and certifications, using periods or no periods)
Name of Business:
(Use if practice has a legal company name)
City: (searchable field)
State: (searchable field)
Zipcode: (searchable field)
Country: (searchable field)
(The search system can only handle one address. If practice has more than one office, second office may be mentioned in descriptive text of listing.)
Phone: (searchable field on area code)
Email:
Website:
(Listing hyperlink limited to one website)
Descriptive text fields:
Space limits restrict these three fields to a cumulative total of about 65 words or 490 characters (dictated by printed version of list). Each modality mentioned here must be documented in the qualifying criteria section above.

Type of healthcare professional - to identify your status list predominant modality, such as Hypnotherapist, Medical Doctor or Wellness Coach. (Note: AHHA policy is to not use "doctor" in identifying type of healthcare professional, unless licensed physician-level trained professional)

Healing modalities offered - to identify what patients/clients can expect. Unless a licensed physician-level trained professional authorized to diagnose and treat serious illnesses, recommend not using terms such as medical, medicine, healing, therapy, treat, or treatment.

Key training - to identify most important/impressive professional training. Include name of degree, training, license, or certification with the name of the related institution. If not room for everything, remember that all training information submitted in qualifying criteria above can be shared with public by AHHA office, on request.

MEMBERSHIP REQUEST:

Yes, I work in partnership with my patients/clients and encourage a holistic approach to wellness, which encourages individuals to:

  • Make lifestyle choices that promote wellness
  • Participate actively in their health decisions and healing processes
  • Balance and integrate their physical, mental, emotional and spiritual aspects
  • Establish healthy and respectful relationships with others and the world around them.

Yes, I grant permission for release of the authorized information for the AHHA Practitioner Member networking list and other public relations opportunities.

Yes, I want to become a Practitioner Member of the AMERICAN HOLISTIC HEALTH ASSOCIATION and certify that the information I have presented 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 you 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

$ 60

$_____





$_____










$

BASIC AHHA PRACTITIONER MEMBERSHIP CONTRIBUTION
 I support the vital work of AHHA! The leading nonprofit wellness and healing information resource, valued by many of the foremost healthcare professionals in America.
$60 is my Practitioner Membership annual contribution

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

ADDITIONAL DONATION
 I understand that nonprofit AHHA remains free and impartial only through donations. In fact, AHHA's work is funded solely by contributions. Therefore, I 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, I 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.
I grant permission to be added to the Honored Donors list

MY COMBINED SUPPORT TO AHHA
Type in the total amount you are contributing. This is the sum of basic $60 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