Membership Invoice Request

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Membership Fees:

Questions:

VAIMH Membership Chair, Melinda Whitehurst, pvaimh@gmail.com

Membership Information

First name*

Last name*

Preferred Email*

Employer*

Professional Title*

What is your Primary Program Type?*

Childcare Center

Early Care & Education

Early Head Start/Head Start Program

EI Local System (Part C/ITC)

Family Day Home

Home Visiting

Mental Health Agency

Public School (Special Ed. Part B)

Virginia Preschool Initiative

Other

Home Street Address

City, State*

Select if you wish to be added to your local VAIMH Chapter*

Central

Eastern

Northern

Piedmont

Western: Accepting Chair volunteer(s)

Opt Out

IECMH Endorsement Status*

I am Endorsed

I am in the process of attaining Endorsement

None of the above

I am interested in volunteering for a VAIMH:

Subcommittee

Board Member Position

N/A

Other

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