CHI Membership Application Form

                                    CENTERING HEALTHCARE INSTITUTE, INC.

                                                                                Membership Application

        Name __________________________________________________

        Name of organiza. ________________________________________

         Address _______________________________________________

                            _____________________________________________________

         Tel: (       ) ______________ Fax (       ) ______________

         E-mail _________________________________________________

         Website: _______________________________________________

         I am applying for an annual membership at the following level:
                                                                                                                                    Amount

         ___ Individual                                                                 $ 50. ....................______

         ___ Institutional / Practice                                           $500......................______

                 ___ Non-profit agency or clinic                          $250......................______

         ___ Lifetime Membership                                            $500......................______

         ___ Please send me information about CHI and how I can start Centering groups in my
            practice.

         ___ Friends of Centering

           I would like to make a tax-deductible contribution to CHI in the amount of:

                                                 - (circle one) $25.   $50.   $100 ..______

                                                 - other amount ..............................______
                                                                                                        __________

                   TOTAL AMOUNT ENCLOSED . . . . . . . . . . . . . .$ _________

      To pay now, via PayPal, click the button to the right -

     (If you pay by PayPal, please copy & fill out the form above and submit it to CHI by fax, mail or e-mail, as
       indicated below, so that they have your complete information.)

       Or orrders may be made by fax, email or regular mail:*
                 CHI, 558 Maple Avenue., Cheshire, CT 06410
                 Tel: (203) 271-3632 / Fax: (203) 272-3460
                 email: info@centeringhealthcare.org (click on, to contact now)

         *This form may be printed out, for fax or regular mail, or copied and pasted into an e-mail.

      For a pdf version of the CHI Membership brochure, with attached application form, click here.