Please select the membership of your choice:

_____ Founding member - One-time Fee of $2500
_____ Sustaining member - Annual Fee of $500
_____ Organizational member - Annual Fee of $300
_____ Individual member - Annual Fee of $100
_____ Associate member - Annual Fee of $1000 

Please provide the following contact information:

Name of Individual or Organization:

______________________________________________________________________

Contact Person for Organization:

______________________________________________________________________

Mailing Address:

______________________________________________________________________

Phone Number:

_______________________________________________________________________

Email Address:

_______________________________________________________________________

Please print this form, fill out the requested information and mail it to address shown on the form.

For more information please contact:
Cathy Britain at csbritain[at]gmail[dot]com or
Jo Bell at membership[at]ortelehealth[dot]org.  

Please mail your completed membership enrollment form and a check in the appropriate amount to:

Jo Bell, Treasurer
Telehealth Alliance of Oregon
c/o OAHHS
4000 Kruse Way
Building 2, Suite 100
Lake Oswego, OR 97035

THANK YOU FOR YOUR SUPPORT!!