HLAA Capital Region Chapter Membership

HLAA Capital Region Chapter Membership Registration

Complete the form below to start the process of becoming a Member!
I am registering as a:*

New MemberExisting Member (Renewal)
Name*

First NameMiddle InitialLast Name
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number:

Area CodePhone Number
I use a special telephone service for telephone calls:

TTYCaption CallNot ApplicableOther
Can we send you e-mails?*

Yes, add me to the e-mail list!Meeting Reminders Onlye-Newsletters OnlyDo NOT e-mail me, please!
E-mail
Birth Date:

MonthDayYear
Where did you hear about us?*

A Friend or colleaugeGoogleWebsiteFacebookDoctor/Audiologist/ProfessionalNewspaperOther
Membership
MEMBERSHIP OPTIONS

-- Individual Chapter Membership: includes newsletter via mail & e-mail, access to Chapter scholarship funds for relevant educational events, support, and more!

-- e-Newsletter Subscription: includes a subscription to our quarterly Chapter newsletter, The Listening Post, via e-mail only. You can also subscribe to the e-Newsletter on our website.
Please select a Membership Option:*

Individual Chapter Membership - $10/yeare-Newsletter only - FREE
I want to help go green!*

Only send the e-Newsletter to help reduce paper and save trees!Sorry, but I prefer to receive the newsletter in the mail.
I also wish to make a donation of:
$
Payment Policy
Payment can be made via check made payable to HLAA Capital Region Chapter.

Please mail checks to:

Jordan Holmes
6308 Auburn Drive
Mechanicsburg, PA 17050
*

I have read, understood, and accepted that I will not become a member or receive member benefits until my payment is received and cleared by HLAA Capital Region Chapter.
Once you submit your application, we will contact you shortly to verify your membership application.

Thank you!
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HLAA Capital Region Chapter Membership Registration

Membership

Payment Policy