Account Registration

New User Sign-Up

Please fill out the account registration form to begin the process of setting up a user account on CHCACT.org. Once approved, your account will be activated.

Question or Comment?

• Name
  
  First
  
  Last
• Email*
  
  Enter Email
  
  Confirm Email
• Username*
• Password
  
  Enter Password
  
  Confirm Password
• Health Center or Organization
• Position / Title
• Phone