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Auxiliary Membership Form

If you would like to complete a printed version of this form, please print a copy of this file.

Membership

Auxiliary

HCMH Employee

Auxiliary Membership

First Name

Middle Initial

Last Name

Phone

Confirm Email

Address

City

State

Zip Code

Membership

1 year - $20

Lifetime - $200

HCMH Employee Membership

1 year - $1

Lifetime - $25

Employee ID

Department

Volunteer

Area(s) you would like to volunteer

Genevieve's Place

Humboldt County Public Health Respite Care / Friendly Visitor / Transportation within City Limits

Payment

Payment Type

Cash/Check

Credit Card