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Membership Application
Order Number
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.
