Application for membership

Please print this page, complete this form and return to the Secretary
c/o: Helen Draper, School of Dentistry, University of Manchester,
Coupland 3, Oxford Road, Manchester M13 9PL UK

I hereby apply for membership of the Institute of Health Promotion and Education as *Full/ Associate/ Corporate /Student Member (*delete as applicable), and agree to abide by the Constitution and Regulations and undertake to pay the Annual Subscription on the 1st January each year and in the event of my resignation I undertake to notify the Secretary in writing and return my Certificate by means of recorded delivery or registered post.

Surname PROF/Dr/Mr/Mrs/Miss/Ms

Forenames

Address

Postcode

Tel (work/home) Email

Honours, awards, decorations7

Degrees or Membership of Professional Institutions:

Name and address of professional reference (required for Member and Fellow grades)

I am at present engaged in Health Promotion/Health Education in a full/ part-time capacity (*delete as applicable).

Present appointment Date Appointed

Organisation

Previous appointments Date

Special Health Education interests:

I enclose initial Registration Fee and Annual Membership Subscription: Total £
I enclose copies of my qualifications and professional memberships.
Please make cheque payable to "Institute of Health Promotion and Education"

Signed Date

Registration Fees		Annual Membership Subscription

Fellow	£10.00	£75.00
Members	£10.00	£36.00
Associate Members	£10.00	£31.50
Corporate Members	£10.00	£45.00
Student Members	£5.00	£25.00
Retired Members	-	£13.50
Transfer between grades £10.00

For Official Use:
Date of Registration: Membership No: