Membership Checkout

Membership Information

You have selected the Affiliate Level 1 membership level.

This membership level is for organizations with more than 100 members, staff, faculty, etc. Three users can be added to the account, in addition to the account administrator.

The price for membership is $577.

Membership expires after 1 Year.

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Account Information

Username

Password

Confirm Password

First Name

Last Name

Email Address

Confirm Email Address

Full Name LEAVE THIS BLANK

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Contact Details

Institution

Department

Address

City

State/Province/Region

Zip Code/Postal Code

Country

Professional Details

Salutation

Degree(s)

Ex. MD, PhD, MBBS, MPH, RN, MSc, etc.

Profession

Organizational Overview

Organization Mission/Profile

Please provide your organization's mission

Organization Website

Please provide the link to your organization's website.

Year Founded

What year was your organization founded?

Current Leadership

Please provide the name of your organization's current Chair, President, or Executive Director.

More Information

How did you hear about WADEM?

Referred by

Group Account Information

This purchase includes 3 additional seats.

Group members will be able to claim the Affiliate Organization - Additional User membership level.

Opt-In Mailing List

Join our mailing list.

WADEM Distribution List

Set your Membership up for Automatic Renewals (Optional)

Select the box & your credit card/PayPal account will be annually billed at $577/Year.

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Payment Information

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Card Number

Expiration Date

CVC

Discount Code

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