VAIMH Membership Form

Membership Information

First name

Last name

Preferred Email

Secondary Email

Employer

Professional Title

What is your Primary Program Type?

Home Street Address

City, State

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

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