Membership Application Name First Name * Last Name * Are you a first time member? * Yes No If yes, how did you hear about GGS? Address for Membership Database (Street Address, City, State, Zip Code) * Optional: Residential Address for Advocacy Alerts Email Address * Can we list your Email in the Membership Database? * Yes No Phone Number * Can we list your Phone Number in the Membership Database? * Yes No Place of Employment? * Position/Title? * Which of these categories do you identify with? * Government/Public/Community Agency or Organization Non-Profit Academia Private Business (For-Profit) Student Retired Other If other, please specify. Which of the following best describes the over-arching service area you work in? * Health Care Delivery - Home or Residential Setting Health Care Delivery - Hospital or Office/Clinic Setting Housing/Residential Setting Home & Community Based Services Legal and/or Financial Services Advocacy/Public Policy Mental Health Education/Training/Work Force Development Not Applicable (Retired or Not Working) Other If other, please specify. Please tell us what profession you consider yourself? * Nurse (RN, LPN, etc.) Advanced Practice Nurse or Physician's Assistant Physician Social Worker/LPC/LMFT/Mental Health Counselor Health or Human Services Program Manager Gerontologist Allied Health Professional Wellness/Activity Specialist/Recreation Marketing/Community Outreach Case Manager/Care Manager OT/PT/Speech Therapist Rehabilitation Professional LTC/Residential Services Patient Advocacy Public Policy Caregiver Professor/Educator Business Owner Lawyer/Legal Services Other If other, please specify. Membership Category? * One Year General Membership - $60 Three Year General Membership - $160 Student Membership (Full or Part Time) - $25 One Year Retired Membership (Not Working Full Time) - $25 Three Year Retired Membership - $65 Non-Profit Organizational Membership - $200 For-Profit Organizational Membership - $300 If applying for student membership, what is the name of your school? If applying for student membership, what degree are you pursuing? If applying for an organizational membership, you can list four additional individuals to receive member benefits. Please list names and email addresses.
