University and Student Group Membership Application

School Name *

Address 1 *

Address 2

Address 3

City

State / Province

Zip / Postal Code

Country *

Are you applying for membership for a specific program, student group, or for an entire university or college? *

If you are applying for a specific program, what is the program? (i.e. Masters in Nursing, Masters in Public Health, etc.)

If you're applying as a student group, please describe the group and its purpose.

How did you hear about CCIH? *

Primary Contact Information. Please complete the fields below for your school's primary point of contact.

First Name *

Last Name *

Title *

Email *

Phone *

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