Member Application

Contact Information

First Name Last Name
Title
Organization
Address
City    State   Zip  
Phone Fax  
Email
Please include your Email address to receive the electronic news publication, the Rural Advocate.
 
Are you currently a member of CSRHA? YES NO
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Affiliation
Community Health Center
Rural Health Clinic
Rural Hospital
Community and Private Practices
Research and Educational Institution
Government Agency
  Association
Foundation
Business & Industry
Consumer / Community Member
Other


Interests
Do you want to collaborate with Rural Health Research Network on grants?
Do you want to participate on the Clinician Advisory Committee? ( The advisory committee meets quarterly via conference call. For more information, click here.)
Are you willing to volunteer to help the Rural Health Research Network answer questions posted by constituents on the website?


In the space provided below, please provide a brief description of your organization and the research topics you and/or your organization are interested in.