Join/Donate

Thank you for your interest in joining or making a donation to HCFANC. Please provide the following contact information, even if you intend to make an anonymous donation, as billing information is required for credit card transactions. By providing a valid email address and password, you are also creating a login to this site. This login will make it quicker for you to join or renew your membership, make a donation, volunteer with our organization, or even share you personal health care story. Note that after you submit this form, you will be logged in on our site, and any time you return to the site, you may login again by entering your email and password in the form provided near the bottom of every page. If you are making an anonymous donation, even though you must provide an email and password, we will not store that information (or any other contact information you provide).

Items marked with an asterisk (*) are required. Please note that your contact information and billing information will NOT be shared with any other organization, and all credit card transactions are handled securely via Moneris Solutions. We currently accept Mastercard, Visa and American Express (both credit and debit cards of these).

Security Issues and Promise

Read the details.

Contact/Billing Info
Title:
First Name:*
Last Name:*
Billing Address:*
Billing Address:
City:*
State (ex. NC)/Zip:*
Email Address:*
Verify email:*
Password:*
Verify Password:*
Home Phone:*
Work Phone:
Mobile Phone:
Best way(s) to contact you:*
Would you like to receive one emailed newsletter each month?*
Yes! No, thank you I am already on the listserv

Choose the option that best suits you:
Become a New Member at $ Become a New Student/Low-Income Member at $ Renew my Membership at $ Renew my Student/Low-Income Membership at $ Become a Member or Renew Membership with a recurring Monthly Donation of $ (to be charged today and then the first of the month, every month for 12 months, starting next month) Make a one-time Donation of $ Make a one-time Anonymous Donation* of $ * We will not store your contact information after validating your credit card for any anonymous donations

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