Houston Eating Disorders Specialists Membership Renewal HOUSTON EATING DISORDERS SPECIALISTS MEMBERSHIP RENEWAL If you are an existing member wanting to renew your membership, please use this form. Membership Renewal Year:* First Name* Last Name* Credentials* Email Address* Enter Email Confirm Email I am renewing my membership as:* Clinical - $50.00 Student - $20.00 Associate - $50.00 Treatment Program - $100.00 HEDS Website and ListservYou will need to provide written permission in order to be included on the HEDS website, www.houstoneds.org, and to be added to HEDS listserv. Please indicate your preference below. Do you want to be included in the HEDS listserv?* Yes No Do you want to be listed on the HEDS website?* Yes No Have you had any disciplinary action taken against your license(s) within the last year?* Yes No Please provide an explaination of the disciplinary action taken against you?Membership ConfirmationPlease electronically sign the form in the space below. Upon submitting the form, you will be directed to Paypal to complete your payment.Media Consent I grant permission for HEDS to take and use images and videos of myself for marketing purposes without further consideration.Please type your name below to indicate that the information you have provided is true and correct to the best of your knowledge.* Δ