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Membership for Patients & Family Members

Please provide the following information to become a member of the Adult Congenital Heart Association. Membership for patients and family members is FREE.

After completing the form, you will receive our monthly e-newsletter, ACHA Update; information about webinars, events and advocacy efforts; and an email linking you to pertinent ACHA materials. In addition, upon becoming a member, you may also register for our Discussion Forum, a place for registered ACHA members to discuss issues with other members of the ACHA community and provide and receive support.

Please read about ACHA's Patient Health Promise by clicking here.

Account Information

Email Address ^*

Password ^*

Confirm Password ^*

* Required fields

Your Information

Salutation

First Name ^*

Last Name ^*

Address (1) ^*

Address (2)

City ^*

State/Region ^*

Zip/Postal Code ^*

Country ^*

Phone Number ^*

Gender

Birth Date ^*

Options

I DO NOT wish to receive communication from ACHA through email

I DO NOT wish to receive communication from ACHA through postal mail

I am interested in volunteering at ACHA

I would like to be contacted by a Heart to Heart Ambassador

I would like to be added to our advocacy list and receive additional information about legislative issues relating to ACHA via email

Please indicate your need for a one-time contact by a Heart to Heart Ambassador: ^*

I am a:

How did you hear about ACHA?:

We want to hear from our members! Please provide your suggestions, ideas, webinar topics, etc. Any questions?