PHA Membership Application (Step 1)

Welcome! We're so glad you're joining our awesome community!
Membership is $10 per month. That includes a listing on wellpdx, member-priced entry to all of our events and workshops, discounts at other local businesses (like the Green Microgym!) and the pleasure of being a part of a like-minded group of wellness practitioners!

We look forward to meeting you,
Amber & Erin, co-founders


First Name


Last Name


Modality


License No. or Certification Info.


Phone Number


Email


Person Who Referred You


Address


Address


City


State


Zip


Website


Reference #1 Name


Reference #1 Contact


Reference #2 Name


Reference #2 Contact


Retype your name here.
By my electronic signature, I am giving consent for Portland Health Alliance to contact me, my references, and to verify any license or certificate information for the purpose of processing my application.

If you are not automatically redirected, return and CLICK HERE to complete your application.