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UMMC Alliance Membership Registration

Thank you for your interest in the UMMC Alliance! There are two payment options for joining the Alliance or renewing your membership. Select the "Cash or Check" option, complete and print the registration form and mail it along with the total payment to the address provided. If you prefer to pay by credit card, select the "Credit Card" option, fill in the credit card information, and hit the Submit button to process your request.

Cash or check

Print this completed form, attach check payable to UMMC Alliance and mail to:
  • UMMC - Room WC-106 (University Hospital)
    Attn. Jamie Thompson
    2500 N. State St.
    Jackson, MS 39216

Registration form

UMMC Alliance Membership Registration Form

Thank you for your interest in the UMMC Alliance! There are two payment options for joining the Alliance or renewing your membership. Select the "Cash or Check" option, complete and print the registration form and mail it along with the total payment to the address provided. If you prefer to pay by credit card, select the "Credit Card" option, fill in the credit card information, and hit the Submit button to process your request.

Cash or Check
Print this completed form, attach check payable to UMMC Alliance and mail to:
UMMC - Room WC-106 (University Hospital)
Attn. Jonathan Albert
2500 North State St.
Jackson, MS 39216

For further information, contact: 601-984-1324.

* = Required Fields

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Phone Number*() -    
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Credit Card Info*
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Credit Card Expiration Date*
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(Located on the back of the card)