Healing Story Membership Form

HSA Member's Only Data Form

For Current Members of the Healing Story Alliance The information here will help us stay current with our mailings to you. The checklist on the work you do and the 50 word description will be important to have for two reasons: first, to give us information about our membership, so that the board can better serve you, and second to provide an online searchable database so that members can contact each other and so that people wanting more information about storytelling in various healing venues can know whom to contact. (Your information will only appear on the online database if you give permission below.)

On-line Database Permission

I Do Do Not want my information
listed in the on-line database

Member Name

^*First:

^*Last:

Internet Connections

^*E-mail address:

Web Site URL:

Mailing Address

^*Street/P.O. Box:

Apartment/suite:

^*City:

^*Zip Code:

^*State/Province:

Country:

^*Phone:

Willing to Travel:

(check all that apply)

Regionally:

Nationally:

Internationally:

Willing to share information with other members:

(check all that apply)

Email:

Phone:

Meetings:

Workshops:

Internships:

I have used storytelling as a focus
of my work in the following areas:

(check all that apply)

adolescent pregnancy:
AIDS awareness/education:
bereavement:
burnout prevention:
community development:
cancer support:
caretaker support:
character development for youth:
chronically ill children or adults:
detention centers:
domestic violence education and support:
early childhood development/interventions:
elder health:
environmental health:
group therapy:
health education/prevention work:
high risk youth/teens:
homelessness:
hospice:
hospital:
incarcerated adults:
peace initiatives:
preserving/sharing cultural identity:
psychiatric:
racial prejudice:
sexuality (identity, homophobia, etc):
staff development/training in using story:
spiritual healing:
substance abuse recovery:
veterans health:
violence prevention:
other:

Have not yet worked specifically with a story in a healing context, but I am particularly interested in the following areas:

Add up to 50 words describing yourself
(This will be included with your on-site database listing):

^*Required Fields

Notes:
• The membership database is updated once a month.
• Newly added membership information will not appear until the database is updated.
• Please, enter your name exactly as it was given to NSN/HSA.
• This form is for HSA members only. Non-member data will not be made available.
• If you are a member of HSA and your membership information does not appear after a month, please contact NSN to check your HSA membership status.
• If your membership status is current with NSN but your membership information does not appear in the database please contact our webmaster, webmaster. Please include your full name.