UCF Student Health Information Management Association

S.H.I.M.A.

UCF Student Health Information Management Association

MEMBERSHIP APPLICATION

Date: ______Senior 0 Junior 0

Name: ______

Mailing Address: ______

Street or P.O. Box

______

City State Zip

Phone: ______Fax: ______Home: ______

Email Address: ______

Permanent Address: ______

Street or P.O. Box

______

City State Zip

What is the best way to reach you? 0 Phone 0 Email 0 Other: ______

Are you currently employed in the healthcare industry? 0 Yes 0 No

Where? ______

Company Position

Would you be interested in participating in any of the following areas? Check all that apply?

0 Fund Raising Activities 0 Mentoring Programs

0 Scrapbook and Bulletin Boards 0 Guest Speakers

0 HIM Awareness Activities 0 Charitable Activities

0 Picnics and Social Events 0 Professional Development

0 Other: ______

What areas of HIM interest you? Check all that apply:

0 Coding 0 Transcription

0 Information Systems 0 Medical Records Management

0 Management 0 Hospitals

0 Long-Term Care 0 Managed Care

0 Physicians Care 0 Insurance Companies

0 Government 0 Undecided

0 Other: ______

RELEASE OF INFORMATION

As a member of the Student Health Information Management Association (SHIMA),

I ______, give consent to the release of my telephone and E-mail to the Officers of SHIMA. This release is for the sole purpose of compiling a Junior/Senior phone list to be distributed among SHIMA members for SHIMA business as follows:

·  Mentor Programs

·  Committee/Chairperson Contact

·  Event Coordination

·  Classmate Consultation

0 Junior 0 Senior

For your convenience, this information may be obtained from the Program Director with your consent.

0 YES, Please OBTAIN my information

0 NO, Please DO NOT use my information

OR, you may provide this information below.

NAME: ______

PHONE: ______

E-MAIL: ______

Please return this application and a check for $15 payable to SHIMA to either the club Treasurer, Mrs. Noblin or Mr. Falen.