Online Application & Renewal Form

 

Fields marked with a are required.

*You must submit either a valid work or home email address for online application.

Already have your Member ID and Password?: Click Here
If Renewal, Check Here:

Please be sure to use the exact First and Last Names used in your last application/update. You will receive correspondence to your preferred email with your new User Id and Password which will permit you to access member only features and make future updates to your member information. If you have any questions or problems using this application, please contact Michelle at mtui@ca.rr.com.

 
Salutation:

(e.g. Mr., Mrs., Dr., etc.)
First Name:
Middle Name:
Last Name:
Suffix:

(e.g. MD, RN, PhD, etc.)
Maiden Name:
UCLA Student ID:
(Required for Student Application)
Membership Category:

Work Information
Title:
Organization Name:
Address 1:
Address 2:
City:
State (2 letter code):
Zip Code:
Country:
Phone Number:
Extension:
Fax Number:
International Fax Number:
Work Email Address:
Primary Employment setting:
Secondary Employment setting:
Last Job Change:
Month
 		Year

Home Information
Address:
City:
State (2 letter code):
Zip Code:
Country:
Phone Number:
Home Email Address:

Degree Information
Degree 1:
Year Obtained:
Degree 2:
Year Obtained:

Contact Preferences

How would you prefer to receive correspondence from HSAA?

Please select preferred Postal Address.

Please select preferred Email Address.

How would you prefer to receive job postings.

Please let us know the main reason for joining UCLA HSAA

Alumni Association Participation

 Yes, I would like to participate and help the association. I would like to volunteer for one or more of the following:

Annual Spring Leaders of Today, Leaders of Tomorrow Recognition Dinner Committee
Alumni/Student Mentor Program
Preceptor
Sponsorship Development (Resume Booklet, Leaders event, Student scholarships)
Other

Are you a Women in Health Administration, (WHA) member?

Additional information we should be aware of: