CSHRM - Connecticut Society for Healthcare Risk Management member application.

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Dear New/Renewing CSHRM Member:

Please complete the following questionnaire and return it along with your membership dues. You may print this page or download the application as a .pdf file.

Member Name: ___________________________________________________

Title: ____________________________________________________________

Employer's Name: _________________________________________________

Employer's Address ________________________________________________
(or address you would like to receive mail)

Employer's Phone: _________________________________________________

Fax Number:______________________________________________________

E-mail Address: ___________________________________________________

Areas of Responsibility: ____________________________________________

_________________________________________________________________

Signature ________________________________________________________

($100.00 for first member and $75.00 for additional members from same institution; student rate $50.)

Committee Participation

I wish to serve/assist on the following committee(s)/activities:
(Please circle all that apply)

1. Membership Committee
2. Finance Committee
3. Education and Program Committee
4. Nominating Committee
5. Policy and Procedure Manual Committee
6. Recognition/Awards Committee

Membership Status: (Please circle choice)

1. New Member
2. CSHRM Renewing Member

Are you a member of ASHRM (American Society for Healthcare Risk Management)?_______
Are you a member of CTAHQ (Connecticut Association Healthcare Quality)?_________
Are you a CPHRM (Certified Professional Healthcare Risk Management)?__________
Are you a CPHQ (Certified Professional Healthcare Quality)?__________

Comments/Suggestions regarding Society activities:

Areas of special interest/suggestions for future educational programs?
What can CSHRM do to better serve you as a member?
Would you like to become actively involved in CSHRM activities?   What type of activities?
Are you currently serving on the Board or any committee? ______Yes ______No
If yes, in what capacity?
Can you proctor/assist new members if needed? ______Yes ______No

PLEASE MAKE YOUR CHECK PAYABLE TO "CSHRM" AND MAIL TO:
($100.00 for first member and $75.00 for additional members from same institution; student rate $50.)

Penny Cafferty
Hospital of St. Raphael
1450 Chapel Street
New Haven, CT 06511

Please Note:
After January 31, 2010 membership fee will be $125 for first member and $100 for additional members from same institution.

Connecticut Society for Healthcare Risk Management
554 Boston Post Road, Suite 147, Orange, Connecticut 06477



home members board application meetings events bylaws newsletter hot topics education links email job postings		application Dear New/Renewing CSHRM Member: Please complete the following questionnaire and return it along with your membership dues. You may print this page or download the application as a .pdf file. Member Name: ___________________________________________________ Title: ____________________________________________________________ Employer's Name: _________________________________________________ Employer's Address ________________________________________________ (or address you would like to receive mail) Employer's Phone: _________________________________________________ Fax Number:______________________________________________________ E-mail Address: ___________________________________________________ Areas of Responsibility: ____________________________________________ _________________________________________________________________ Signature ________________________________________________________ ($100.00 for first member and $75.00 for additional members from same institution; student rate $50.) Committee Participation I wish to serve/assist on the following committee(s)/activities: (Please circle all that apply) 1. Membership Committee 2. Finance Committee 3. Education and Program Committee 4. Nominating Committee 5. Policy and Procedure Manual Committee 6. Recognition/Awards Committee Membership Status: (Please circle choice) 1. New Member 2. CSHRM Renewing Member Are you a member of ASHRM (American Society for Healthcare Risk Management)?_______ Are you a member of CTAHQ (Connecticut Association Healthcare Quality)?_________ Are you a CPHRM (Certified Professional Healthcare Risk Management)?__________ Are you a CPHQ (Certified Professional Healthcare Quality)?__________ Comments/Suggestions regarding Society activities: Areas of special interest/suggestions for future educational programs? What can CSHRM do to better serve you as a member? Would you like to become actively involved in CSHRM activities? What type of activities? Are you currently serving on the Board or any committee? ______Yes ______No If yes, in what capacity? Can you proctor/assist new members if needed? ______Yes ______No PLEASE MAKE YOUR CHECK PAYABLE TO "CSHRM" AND MAIL TO: ($100.00 for first member and $75.00 for additional members from same institution; student rate $50.) Penny Cafferty Hospital of St. Raphael 1450 Chapel Street New Haven, CT 06511 Please Note: After January 31, 2010 membership fee will be $125 for first member and $100 for additional members from same institution.

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Connecticut Society for Healthcare Risk Management 554 Boston Post Road, Suite 147, Orange, Connecticut 06477 Copyright © 2008-2010 – Connecticut Society Healthcare Risk Mangers (CSHRM) All rights reserved.