Council on Black Health Membership Application Email Address *SalutationMissMs.Mrs.Mr.Dr.First Name: *Preferred Name:Last Name: *Title:Affiliation, Institution/Organization: *Department:Position within Organization *Preferred Mailing Address 1: *Preferred Mailing Address 2:Preferred Mailing Address City *Preferred Mailing Address State/Province: *Preferred Mailing Address Zip/Postal Code: *Preferred Mailing Address Country: AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabwePhone Number: *Fax Number:Website:Professional Twitter Handle:Professional LinkedIn:Professional Instagram:Membership LevelIndividualIndividual, EmeritusStudent/TraineeOrganizationalPlease contact me about prorated membershipYesNoAreas of Expertise/Research/Program Interests(Please check all that apply)Body ImageBuilt EnvironmentCampus and Communitiy PartnershipsCommunity-Based Health CareCommunity-Based InterventionsCommunity-Based Participatory ResearchCommunity OrganizingCultural CompetencyCultural IdentityDiabetes ManagementEating Behavior in Children/AdolescentsEnvironmental IssuesEpidemiologyEthnicityFaith-Based IssuesFamily ContextGenderHealth Disparities/Health EquityHealth EducationHealth PolicyHeart DiseaseHypertensionMarketing/Media InfluencesMinority HealthMultiple Metabolic Syndrome (or Syndrome X)NutritionObesity in Children/AdolescentsObesity InterventionsPhysical ActivityPolitical Determinants of HealthPubertal MaturationQualitative/Ethnographic Research MethodsRecruitmentResearch Study DesignSmoking CessationSocial/Economic StatusSocial Determinants of HealthType 2 DiabetesOtherServe on a CommitteeThe support of Council on Black Health members is critical for our success. If you are interested in serving a one-year term on a Council on Black Health standing subcommittee, please indicate your interest below:Policy and AdvocacyThis committee will be responsible for tracking policy relevant to the Council on Black Health’s research agenda. Committee members should have an interest in current events, and have experience or interest in advocacy work. This committee will be influential in understanding the political implications of the work conducted by the Council and its members.Partnership and Membership ServicesThis committee will be responsible for reviewing the operational needs of the Council on Black Health members and member sites. Committee members should have experience or interest in infrastructure development, creating and reviewing guiding documents, and organizational problem solving.Research and ProgramsThis committee will be responsible for identifying research and program opportunities, advising on assembly project advisory teams, and reviewing manuscripts prior to publication submission. Committee members should have experience or interest in … Mentorship and Career DevelopmentThis committee will be responsible for identifying mentorship and career development opportunities for Council members. Committee members should have experience or interest in fostering professional growth and supporting career development.Conference PlanningThis committee will be responsible for advising on conference content, location planning, and member experience for annual conferences (and others as needed). Committee members should have experience or interest in event coordination.CommunicationsThis committee will be responsible for advising on the development of external communication materials and use of the Council’s social media accounts. Committee members should have experience or interest in various external communication channels (social media, journalism, etc.) and creative marketing strategies.Finance, Fundraising, and AwardsFundraising and awards management are vital to the operation of the Council on Black Health. This committee will be responsible for identifying and advising on the application of potential funding opportunities. This committee will also coordinate and advise on fundraising events for the Council. Members of this committee should have experience or interest in identifying and applying for funding opportunities, and should have experience or interest in networking and fostering relationships with fiscal donors.Rapid ResponseThis committee is a group of Council members that can convene quickly to discuss time sensitive topics. Committee members should be available join committee calls with short notice, ability to offer prompt responses to email for important issues, and can use quick-thinking skills to make informed decisions and recommendations.I cannot serve on a standing subcommittee but would like to be contacted to serve on ad hoc subcommittees.Submit FormPlease do not fill in this field. Pay your Membership Dues Membership Options Individual $200.00 USD Student/Trainee $75.00 USD Organization $700.00 USD