Charitable Healthcare Network Associate Member Application
Individuals and Organizations wishing to become an Associate Partner must meet the following criteria:

- Support the mission of the Charitable Healthcare Network
- Commit to supporting Charitable Healthcare Networks efforts to provide quality care
- Commit to minimizing barriers to care
- Support Charitable Healthcare Network financially when able

Note: Associate Members are not voting members of the Charitable Healthcare Network
Email address *
Name of individual completing this application *
Full legal name of the organization: *
If you are an individual applying for membership, please provide your first and last name
Organization Description
Organization website (if applicable)
Senior staff member name and title *
Primary contact
Senior staff member phone *
Primary contact
Senior staff member email *
Primary contact
Mailing Address
If more than one staff person/ volunteer should be included in mailings, please include a separate list, including full name, email and mailing address for each individual. *
Associate Member type *
I acknowledge there is a $100 non-refundable application fee whose invoice will be sent to the email address completing this application. *
Required
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