2017 Membership Application

 

SHIMA

Seattle Health Information Management Association

Personal Information

First Name___________________________________________________________

Last Name___________________________________________________________

Email Address________________________________________________________

Today's Date__________________________________________________________

Professional Information

Employer Information__________________________________________________

Your Job Title / Function________________________________________________

Credentials

__RHIA    __RHIT   __CCS   __CHPS   __Student   __Other______________________

Education Information

If you are currently a student where are you enrolled? 

____________________________________________________________________

What program of study are you involved in? 

_______________________________________________

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

Membership Type

___Student $5.00   ___Professional $20.00

SHIMA
P.O. Box 95264
Seattle, WA

98145