Membership Application Form

Please complete the following Pennsylvania Mental Health Consumers' Association membership application form.

At the end of the page, click the button to "Go to Payment Page", where you will be able to select a membership level and pay your membership fee using PayPal.

If you have any questions call 800-887-6422.

Are you a new member or are you renewing an expired membership?

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* Are you a new member or are you renewing an expired membership?

First name:

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* First name:

Last name:

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* Last name:

Organization name (for corporate membership):

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* Organization name (for corporate membership):

Address:

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* Address:

Address (if needed, second line):

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* Address (if needed, second line):

City:

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* City:

State:

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* State:

Zip:

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* Zip:

County:

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* County:

Email:

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* Email:

Secondary email:

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* Secondary email:

Home Phone:

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* Home Phone:

Work phone:

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* Work phone:

Click on the link to go to the payment option page to complete your membership.
I would like to receive a PDF version of the PMHCA Vision newsletter via email instead of by postal mail.

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* I would like to receive a PDF version of the PMHCA Vision newsletter via email instead of by postal mail.

Is this a gift membership?

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* Is this a gift membership?

If you answered yes to the above question, would you like us to send an email acknowledging the gift in your name?

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* If you answered yes to the above question, would you like us to send an email acknowledging the gift in your name?

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