Membership Form

Academy of Correctional Health Professionals

Membership Form
Name

First Name Last Name
Gender
Job Title
Primary Employer
Professional Training

Administrator Attorney Nurse Nurse Practitioner Pharmacist Physician Physician Assistant Psychiatrist Psychologist Social Worker Other
If Other, please specify
Work setting for the majority of your correctional work

Advocacy Federal/ICE State DOC University County/City Jail Federal Prison State Juvenile Department of Health Hospital State Prison Other
If Other, please specify

Address

Shipping Address

Phone Number

- Area Code Phone Number
Mobile Phone Number

- Area Code Phone Number
Fax Number

- Area Code Phone Number
E-mail
If you are a Certified Correctional Health Professional (CCHP), you qualify for a discounted membership in the Academy. You may submit an Academy renewal form or renew with your registration to any NCCHC conference.
I am not currently certified by the National Commission on Correctional Health Care, but am interested in learning more about certification.

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Academy of Correctional Health Professionals