Rural Health Clinic-Constituency Section Registration










             Name of Organization/hospital

   RHC:
  
  
  
  
   








Nebraska Rural Health Association
If you are registering more then one Rural Health Clinic please provide information for each Clinic below!
E-mail
Phone
City, State, Zip
Address
Contact Person
Please mail payment payable to:

Nebraska Rural Health Association
2222 Stone Creek Loop South
Lincoln, NE 68512
$150.00 for the first RHC
$50.00 for each additional RHC
Yes our RHC would like to become a member of the RHC-CS of the NeRHA!
We currently have a NeRHA organizational (hospital) membership, please add a RHC to this membership!