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2017 Membership Application

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SHIMA

Seattle Health Information Management Association

Personal Information

First Name___________________________________________________________

Last Name___________________________________________________________

Email Address________________________________________________________

Today's Date__________________________________________________________

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Professional Information

Employer Information__________________________________________________

Your Job Title / Function________________________________________________

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Credentials

__RHIA    __RHIT   __CCS   __CHPS   __Student   __Other______________________

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Education Information

If you are currently a student where are you enrolled? 

____________________________________________________________________

What program of study are you involved in? 

_______________________________________________

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Volunteer Information

I would like to know more about voluntering for SHIMA. 

__Yes   __No

I would like to be involved with SHIMA in the following area(s). 

__Communication Committee    __Education Committee   __Finance  Committee

__Outreach Committee   __Scholarship Committee   __Technology Committee

__Unsure but excited to be involved

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Membership Type

___Student $5.00   ___Professional $20.00

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