CIAND Membership Form

Member Information
Name:*
First Middle Initial Last Credentials
Address:*
Street Address Address Line 2 City State ZIP Code
Primary Phone:*
Work Phone:
Email:*
Place of Employment:*
Registration Status
CIAND uses the Internet to distribute information on job openings, legislation, meetings and other items of interest. CIAND DOES NOT share or distribute our e-mail with any organization. If you wish to not be listed please let us know via e-mail.
Please publish my e-mail address in the CIAND membership directory.*
- Yes
- No
Please include my e-mail address on the CIAND Google distribution list used to communicate upcoming events and information to CIAND members.*
- Yes
- No
Academy Membership Number:*
Registration Status & Dues*
Practice Key Area
Clinical
- 1. Clinical Inborn Errors
- 2. Allergy / Celiac Disease
- 3. Cardiac
- 4. Consulting in facilities
- 5. Diabetes, Adult
- 6. Diabetes, Peds
- 7. Eating disorders
- 8. GI Disorders / Surgery
- 9. Geriatrics/Long Term Care
- 10. High-Risk Infants
- 11. HIV / AIDS
- 12. Inborn Errors
- 13. Nutrition Support, Adult
- 14. Nutrition Support, Peds
- 15. Oncology, Adults
- 16. Oncology, Pediatric
- 17. Pediatric Nutrition
- 18. Pediatric Special Needs
- 19. Rehab, Adult
- 20. Rehab, Pediatrics
- 21. Renal Specialist
- 22. Substance Abuse
- 23. Transplant
- 24. Weight Management
Management
- 25. Computer / Informatics
- 26. Foodservice Management
- 27. Management
- 28. Healthcare Administration
- 29. Multi-Department Management
- 30. Multi-Facility Management
- 31. Organization Development
- 32. Retail Merchandising
- 33. Sales / Marketing
Education
- 34. Educator, dietetics students
- 35. Education, Other
Education, Other -- Please Specify:*
Community Wellness
- 36. Cooking
- 37. Classes/Demos/Grocery Tours
- 38. Public Health/Community
- 39. Nutrition Communication
- 40. Sports Nutrition Wellness
Other: 41. Practice Specific, Care -- Please Specify:

Please list any continuing education interests that you would like to have fulfilled to help CIAND with future program planning:

I would like to serve on the following committees:
- CPI – assist the CPI with planning, implementing, completing Educational meetings (6-7 meetings / year)
- National Nutrition Month – assist the NNM chair with planning / implementing NNM activities
- Newsletter Assistance – write / contribute pictures / articles to the Newsletter There are 4 newsletters / year
- Public speaking / Media – volunteer with television / radio requests / CIAND speaker bureau
- Public Relations / Legislative Representative
Payment
Payment Options*
- Pay by Check
- Pay by Credit/Debit Card
Make checks payable to CIAND & mail to:
Kate Beard
501 Vista Dr.
Carmel, IN 46280
Payment Due:
$0.00

DUE DATE: September 30, 2022

Member Information

Registration Status

Practice Key Area

Payment

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