AHP Members Only - Member Record Update Form

ST/Province

Zip/Postal code

E-mail address

Member Record Update Form

We need your help to maintain accurate records! Check your listing now and provide us with any corrections as needed. We are providing this form for you to let us know of any changes as they occur. Records will be updated online and at the AHP International Office.

Directory Information

First name		M.I.		Last name		Suffix

Title		Healthcare organization

Organization street address

Personal Information

Home street address

Individual Information

Year you began career development				(i.e. 1985)
Year began career in health care development				(i.e. 1985)

Primary responsibilities in current position include: (choose all that apply):

Direct Mail

Annual Gifts

Capital Campaigns

Major Gifts

Marketing

Communications

Special Events

Planned Giving

Corporations/Foundations

Other

** Gender

Male

Female

** Ethnicity

White (not of Hispanic origin)

Hispanic

African American/Black

Other

Asian/Pacific Islander

American Indian/Alaskan Native

** What year were you born?

**	Optional: will not be shared or viewed externally. This information will be used internally for demoraphic/statistical purposes only.

Institution Information

Name of Healthcare/Hospital System

Institution's CEO

Institution's Web address

Service population (est.)

Number of beds

as reported to AHA

Type of health care facility

please choose all that apply

		Children's Hospital
		Hospice
		Nursing/Retirement Home
		Multi-hospital system
		University-based
		Community Hospital
		Long-term care
		Psychiatric
		Rehabilitation
		Voluntary Heatlh Agency
		Community Med. Center
		Medical School
		Government
		Teaching
		VNA

The online membership directory is provided for those who have a specific interest in finding an AHP member or affiliate member. Information obtained from this directory may not be used to provide addresses for mailings to AHP members or their institutions. Any solicitation of business, contributions or other response from members and organizations listed on this Web site by mail, telephone or other means is prohibited.