LASHRM

Name:                                                                                                                                 

Title:                                                                                                                                   

Employer:                                                               

Phone #:                                                                    

Mailing Address:                                                                                                               

City:                                                    State:                              

Zip Code:                         

Years in Risk Management:                                              

Membership in ASHRM (Yes/No):                                   

Email Address:                                                  Fax #:                                

Primarily responsible for:                                                      

New Application:____________  Renewal:___________

DUES                                                                               

q $40.00 Annually – Regular Membership

Individuals who are actively involved in risk management related activities in a hospital, a managed-care organization, or another     healthcare provider organization   involved in the continuum of care, an insurance company, an insurance agency, a consultancy, academia, or a defense attorney not associated with a law firm which represents plaintiffs in medical malpractice matters.  Regular members are     eligible to vote, hold office, and serve on Committees.

q $20.00 Annually – Student Membership

Any full-time student registered at an accredited institution of higher learning in a curriculum of or related to healthcare or healthcare risk management and who has an interest in the field of risk management.  Student Members are not eligible to vote or hold office.