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
* Required
Email address
*
Your email
Name of individual completing this application
*
Your answer
Full legal name of the organization:
*
If you are an individual applying for membership, please provide your first and last name
Your answer
Organization Description
Your answer
Organization website (if applicable)
Your answer
Senior staff member name and title
*
Primary contact
Your answer
Senior staff member phone
*
Primary contact
Your answer
Senior staff member email
*
Primary contact
Your answer
Mailing Address
Your answer
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.
*
Your answer
Associate Member type
*
Individual ($100/year)
Nonprofit Partner ($500/year)
For-Profit Partner ($1,000/year)
I acknowledge there is a $100 non-refundable application fee whose invoice will be sent to the email address completing this application.
*
Yes
Required
Submit
Page 1 of 1
Never submit passwords through Google Forms.
This form was created inside of Charitable Healthcare Network.
Report Abuse
Forms
