Become a Member

Thank you for your interest in joining MAGIC! Please fill out the application below. After hitting submit, you will be prompted to pay via PayPal. If you prefer to pay by check, please submit your payment to:

MAGIC Office
P.O. Box 24475
Minneapolis, Minnesota 55424:

New Membership Application

* Indicates required field

Name *

First

Last

Credentials *

Preferred Address *

Line 1

Line 2

City

State

Zip Code

Country

Cell Phone *

Office Phone *

Email *

Medical Directors please complete this section.

Please list the name(s) and location(s) of the facilities where you serve as medical director.

Facility Address *

Line 1

Line 2

City

State

Zip Code

Country

Administrator's Name *

First

Last

Phone Number *

Elected *

Date *

Facility Name *

Facility Address *

Line 1

Line 2

City

State

Zip Code

Country

Administrator's Name *

First

Last

Phone Number *

Administrator's Name *

Submit