Membership Form

What Membership Type are you applying for?*
Pronoun
Name*
First Middle Last Suffix
Preferred Name
Job Title*
Designations
Work Email*
Personal Email

For staying in contact if you leave your organization or email convention changes, etc.
Date of Birth
MM slash DD slash YYYY
Current Organization Name*
What best describes your organization?*
What is your Organizations Gross Revenue*
What is the number of Staffed Inpatient Beds*
What is the title of the person you report to?*
Work Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Work Phone
Cell Phone
Assistant Name
First Last
Assistant Email
LinkedIn
Twitter
Facebook
Job Description*
Max. file size: 1 GB.
Job description or a brief statement of your areas of accountability
IT Department Organizational Chart*
Max. file size: 1 GB.
How did you hear about CHIME?*
Privacy Policy*
- Check here to indicate that you have read and agree to the CHIME privacy policy terms.
Privacy Policy- https://chimecentral.org/privacy-policy/
Questions? Contact Us: Should you have other questions or concerns about these privacy policies, please call us at 734.665.0000 or send us an email to [email protected].