Member/Provider Registration

I am submitting my registration to become a: (check all that apply)

Member (You will receive periodic emails regarding upcoming events and relevant issues and will be listed on our membership roster.)

Provider (You will be listed in our provider database and your information will be available to individuals through our "Find a Provider" directory.)


Please provide the following information.

First Name:      

Last Name:      

Organization:   

Address:          

City:                           

State:              

Zip Code:         

Phone Number:

E-mail Address:

Password: (This password will be needed when returning to the site to update your information.)

If you have any questions please contact Virginia Rediske at (319) 384-4566 or by email at icmha@uiowa.edu.