NDHA Membership Application Form

Membership Application

Please complete the following information to join our organization. All fields marked with an asterisk (*) are required.

Personal Information

First Name

Last Name

Date of Birth (month/day)

Email Address

Phone Number

Mailing Address

City

State

Zip

Country

License Information

License State

License Number

Credentials (BS,MS, Ph.D Ed.D)

Dental Hygiene School Attended or Attending

Graduation Year

Membership Details

Membership Type

General Membership - $180/yearDH Student Membership - $40/yearRetired Membership - $80/year

Payment Calculation

Total Annual Amount

Payment Information

Payment Method: Stripe (Credit Card or ACH)

After submitting this application, you will be redirected to Stripe to securely complete your membership payment.

For General & Retired Members: You can cancel your auto-renewal anytime through your Stripe customer portal. A link will be provided in your payment confirmation email, or you can contact us at ndhaltweb@gmail.com for assistance.

For Student Members: Your membership is a one-time annual payment with no auto-renewal.

Agreement and Terms

Membership Terms & Payment:

Membership is valid for one year from the date of payment
General & Retired Members: Your membership will automatically renew each year on the anniversary date. Stripe will automatically charge your selected payment method annually.
Cancellation: General and Retired members can cancel auto-renewal anytime through your Stripe customer portal - no fees or penalties. Access your portal through the link in your payment confirmation email or contact us at ndhaltweb@gmail.com.
Student Members: One-time annual payment, no automatic renewal (must reapply and pay each year)
Lifetime Members: No renewal required
We may use your email address for membership updates and organizational news

By submitting this application, General and Retired members authorize automatic annual renewal and payment processing through Stripe. Student and Lifetime members make one-time payments only.

I agree to the membership terms and conditions

Yes, I agree

I authorize payment processing (and automatic renewal if applicable)

Yes, I authorize Stripe to process my payment and, if applicable, automatically renew my membership

Disclaimer

By submitting this form, you are agreeing to receiving promotional emails.

Contact Information