Individual Registration

First Name  *

Last Name  *

Job Title  *

Organization  *

--Select-- 4th Street Clinic (Wasatch Homeless Health Care, Inc.) Bear Lake Community Health Center Carbon Medical Service Association Community Health Centers, Inc. Creek Valley Health Clinic Enterprise Valley Medical Clinic Family Healthcare Four Points Community Health Centers Green River Medical Center, Inc. Midtown Community Health Center, Inc. Mountainlands Family Health Center, Inc. Utah Navajo Health Systems, Inc. Utah Partners for Health Wayne Community Health Center, Inc. First Step House Odyssey House Sacred Circle Healthcare Urban Indian Center of Salt Lake AUCH Other

If other, please list your organization.  *

Email  *

MHFA Payment  *

$0 AUCH Member

$40 Non-Member

Amount

$

Payment Method

Stripe

Credit Card Number*

Expiration Date*

01 02 03 04 05 06 07 08 09 10 11 12 / 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033

Card (CVV) Code*

Card Holder Name*