SHIMA
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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