Membership Application and Directory Information
July 1, 2017 to June 30, 2018
For office use only:
Treasurer: Check number: ______Total enclosed: ______Date rec’d: ______
Membership Secretary: Added to directory: ______Email updated______
*Service fee will be applied for credit card payments online.
Please complete application with check made payable to CCLHDN
Tax ID# 68-0427712
Send to:
Rhea Napeek
Yolo County Health & Human Services Agency
25 N Cottonwood St.
Woodland, CA 95695
NOTE: The CCLHDN W-9 was included with the application that was emailed to you.
For questions, E-mail
OR call Rhea Napeek at:
(530) 666-8456
CCLHDN MEMBERSHIP DUES*
Due by December 31, 2017
LHD RD/RDN Member $ 150 _____
Non LHD RD/RDN/DN $ 200 _____
Student Member Free _____
For office use only:
Treasurer: Check number: ______Total enclosed: ______Date rec’d: ______
Membership Secretary: Added to directory: ______Email updated______
*Service fee will be applied for credit card payments online.
Primary Registered Dietitian Member (appointed by the Health Officer) Contact Information
Name (First Name, Last Name) Credentials
Title Area of Work (i.e. SNAP-Ed/NEOP, WIC, School Wellness, Retail)
Name of Organization
Representative County
Address (street number, street name, apartment/suite), City, State, Zip
( )
Work phone Email Address
Does your agency have other RD/RDN staff that will be involved in CCLHDN? Y____N____
Please list their name and e-mail address below:
Name: / Email:1.
2.
3.
4.
5.
6.
Please note that membership is complimentary for additional agency nutritionists.
Photo Release: With this membership application I grant to CCLHDN its representatives and employees the right to take photographs of me and my property in connection with its activities. I authorize CCLHDN, its assignees and transferees to copyright, use and publish the same in print and/or electronically. I agree that CCLHDN may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
For office use only:
Treasurer: Check number: ______Total enclosed: ______Date rec’d: ______
Membership Secretary: Added to directory: ______Email updated______
*Service fee will be applied for credit card payments online.